Provider First Line Business Practice Location Address:
200 ST MARYS MEDICAL PLAZA
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
JEFFERSON CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-636-5248
Provider Business Practice Location Address Fax Number:
573-635-1575
Provider Enumeration Date:
08/31/2006