Provider First Line Business Practice Location Address: 
213 US HIGHWAY 60 W
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
REPUBLIC
    Provider Business Practice Location Address State Name: 
MO
    Provider Business Practice Location Address Postal Code: 
65738-1432
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
417-732-2344
    Provider Business Practice Location Address Fax Number: 
417-732-6014
    Provider Enumeration Date: 
10/12/2006