Provider First Line Business Practice Location Address:
1313 S RANGE LINE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOPLIN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64801-5588
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-623-2207
Provider Business Practice Location Address Fax Number:
417-623-0342
Provider Enumeration Date:
10/23/2006