Provider First Line Business Practice Location Address: 
1300 E BRADFORD PKWY
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SPRINGFIELD
    Provider Business Practice Location Address State Name: 
MO
    Provider Business Practice Location Address Postal Code: 
65804-4294
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
417-761-5000
    Provider Business Practice Location Address Fax Number: 
417-761-5100
    Provider Enumeration Date: 
07/26/2018