Provider First Line Business Practice Location Address:
14982 OLD HIGHWAY 63
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA PLATA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63549-4009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-332-7296
Provider Business Practice Location Address Fax Number:
660-332-7390
Provider Enumeration Date:
03/12/2008