Provider First Line Business Practice Location Address: 
620A N MCKNIGHT RD
    Provider Second Line Business Practice Location Address: 
SUITE 2A
    Provider Business Practice Location Address City Name: 
UNIVERSITY CITY
    Provider Business Practice Location Address State Name: 
MO
    Provider Business Practice Location Address Postal Code: 
63132
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
314-432-5988
    Provider Business Practice Location Address Fax Number: 
314-432-2074
    Provider Enumeration Date: 
08/30/2006