Provider First Line Business Practice Location Address: 
1621 TOWNE DR
    Provider Second Line Business Practice Location Address: 
STE C
    Provider Business Practice Location Address City Name: 
COLUMBIA
    Provider Business Practice Location Address State Name: 
MO
    Provider Business Practice Location Address Postal Code: 
65202-3654
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
572-474-8800
    Provider Business Practice Location Address Fax Number: 
572-474-8088
    Provider Enumeration Date: 
02/25/2009