Provider First Line Business Practice Location Address:
2530 LUCY LEE PKWY STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POPLAR BLUFF
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63901-2436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-785-8766
Provider Business Practice Location Address Fax Number:
573-785-8769
Provider Enumeration Date:
10/28/2006