Provider First Line Business Practice Location Address:
201 A SOUTH LAKE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MTN GROVE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-234-1812
Provider Business Practice Location Address Fax Number:
417-942-5238
Provider Enumeration Date:
05/21/2013