Provider First Line Business Practice Location Address: 
3522 US HIGHWAY 169
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
STANBERRY
    Provider Business Practice Location Address State Name: 
MO
    Provider Business Practice Location Address Postal Code: 
64489-8210
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
660-783-2628
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/07/2007