Provider First Line Business Practice Location Address: 
1545 E PYTHIAN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SPRINGFIELD
    Provider Business Practice Location Address State Name: 
MO
    Provider Business Practice Location Address Postal Code: 
65802-2139
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
417-829-0893
    Provider Business Practice Location Address Fax Number: 
417-831-7539
    Provider Enumeration Date: 
11/14/2006