Provider First Line Business Practice Location Address:
109 E 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORUTHERSVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-333-1550
Provider Business Practice Location Address Fax Number:
573-333-0055
Provider Enumeration Date:
10/31/2006