Provider First Line Business Practice Location Address: 
509 S UNION AVE
    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: 
65802-2659
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
417-865-2900
    Provider Business Practice Location Address Fax Number: 
417-865-2901
    Provider Enumeration Date: 
10/14/2008