Provider First Line Business Practice Location Address:
408 VINE ST
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:
63901-5838
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-686-1118
Provider Business Practice Location Address Fax Number:
573-686-5109
Provider Enumeration Date:
08/02/2010