Provider First Line Business Practice Location Address:
124 N WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST PRAIRIE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63845-1140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-649-3923
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/19/2007