Provider First Line Business Practice Location Address:
138 S MAIN ST
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
LAURIE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65037-6196
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-374-2200
Provider Business Practice Location Address Fax Number:
573-374-7441
Provider Enumeration Date:
06/22/2005