Provider First Line Business Practice Location Address:
216 S KINGSHIGHWAY BLVD
Provider Second Line Business Practice Location Address:
MS# 90-52-411
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63110-1026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-747-0442
Provider Business Practice Location Address Fax Number:
314-362-0088
Provider Enumeration Date:
08/26/2005