Provider First Line Business Practice Location Address:
12 W 19TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIGGINSVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64037-1507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-584-2927
Provider Business Practice Location Address Fax Number:
660-584-7444
Provider Enumeration Date:
07/07/2006