Provider First Line Business Practice Location Address: 
215 E HIGH ST STE 5
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
POTOSI
    Provider Business Practice Location Address State Name: 
MO
    Provider Business Practice Location Address Postal Code: 
63664-1950
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
573-210-4049
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/08/2011