Provider First Line Business Practice Location Address: 
1300 PENNELL ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CARL JUNCTION
    Provider Business Practice Location Address State Name: 
MO
    Provider Business Practice Location Address Postal Code: 
64834-9478
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
417-649-7600
    Provider Business Practice Location Address Fax Number: 
417-649-7518
    Provider Enumeration Date: 
09/22/2009