Provider First Line Business Practice Location Address:
1653 S HIGHWAY 65 82
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE VILLAGE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71653-1661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-536-0734
Provider Business Practice Location Address Fax Number:
870-534-8378
Provider Enumeration Date:
11/04/2005