Provider First Line Business Practice Location Address:
1207 E ROOSEVELT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65560-9676
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-729-9449
Provider Business Practice Location Address Fax Number:
573-729-8719
Provider Enumeration Date:
06/30/2005