Provider First Line Business Practice Location Address:
420 E HIGH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEFFERSON CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65101-3215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-635-0916
Provider Business Practice Location Address Fax Number:
573-635-8812
Provider Enumeration Date:
10/17/2006