Provider First Line Business Practice Location Address: 
536 N TAYLOR AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SAINT LOUIS
    Provider Business Practice Location Address State Name: 
MO
    Provider Business Practice Location Address Postal Code: 
63108-1888
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
314-449-1143
    Provider Business Practice Location Address Fax Number: 
314-449-1724
    Provider Enumeration Date: 
09/02/2011