Provider First Line Business Practice Location Address:
100 S BATES ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAYNESVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65583-2146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-774-5894
Provider Business Practice Location Address Fax Number:
573-774-6975
Provider Enumeration Date:
06/25/2007