Provider First Line Business Practice Location Address:
1121 HISTORIC ROUTE 66 WEST
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-774-0053
Provider Business Practice Location Address Fax Number:
573-774-3053
Provider Enumeration Date:
02/05/2007