Provider First Line Business Practice Location Address:
101 NORTH MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LICKING
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-674-2922
Provider Business Practice Location Address Fax Number:
573-674-4334
Provider Enumeration Date:
08/23/2007