Provider First Line Business Practice Location Address:
1519 E LARK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65804-7316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-881-3278
Provider Business Practice Location Address Fax Number:
417-881-2278
Provider Enumeration Date:
03/29/2011