Provider First Line Business Practice Location Address:
411 CENTRAL METHODIST SQ
Provider Second Line Business Practice Location Address:
ATHLETIC TRAINING
Provider Business Practice Location Address City Name:
FAYETTE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65248-1104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-248-6978
Provider Business Practice Location Address Fax Number:
660-248-6381
Provider Enumeration Date:
08/03/2016