Provider First Line Business Practice Location Address:
3071 HIGHWAY 15
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBYVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63469-2225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-633-2401
Provider Business Practice Location Address Fax Number:
573-633-2138
Provider Enumeration Date:
02/15/2007