Provider First Line Business Practice Location Address:
105 SW 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK GROVE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64075-0957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-625-4580
Provider Business Practice Location Address Fax Number:
816-625-4580
Provider Enumeration Date:
11/18/2005