Provider First Line Business Practice Location Address:
600 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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-785-5343
Provider Business Practice Location Address Fax Number:
573-785-3806
Provider Enumeration Date:
07/11/2007