Provider First Line Business Practice Location Address:
119 EAST 4TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEDALIA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-553-5298
Provider Business Practice Location Address Fax Number:
660-553-5301
Provider Enumeration Date:
08/25/2006