Provider First Line Business Practice Location Address:
493 REPLACEMENT AVENUE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
FORT LEONARD WOOD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-596-0119
Provider Business Practice Location Address Fax Number:
573-596-0818
Provider Enumeration Date:
10/02/2012