Provider First Line Business Practice Location Address: 
1421 S RANGE LINE RD STE C
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
JOPLIN
    Provider Business Practice Location Address State Name: 
MO
    Provider Business Practice Location Address Postal Code: 
64801-5996
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
417-434-9445
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/24/2007