Provider First Line Business Practice Location Address:
16 W. 4TH ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANT CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-564-3322
Provider Business Practice Location Address Fax Number:
660-564-3324
Provider Enumeration Date:
02/08/2007