Provider First Line Business Practice Location Address:
2503 LUCY LEE PKWY
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:
63901-2444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-785-5544
Provider Business Practice Location Address Fax Number:
573-785-4672
Provider Enumeration Date:
08/31/2006