Provider First Line Business Practice Location Address:
101 NORTH MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LICKING
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65542-9026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-674-3932
Provider Business Practice Location Address Fax Number:
573-674-4334
Provider Enumeration Date:
07/20/2012