Provider First Line Business Practice Location Address:
1301 W PHELPS ST
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:
65802-4234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-619-5954
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/22/2006