Provider First Line Business Practice Location Address: 
2701 ROGERS AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FORT SMITH
    Provider Business Practice Location Address State Name: 
AR
    Provider Business Practice Location Address Postal Code: 
72901-4225
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
497-783-4782
    Provider Business Practice Location Address Fax Number: 
479-783-7092
    Provider Enumeration Date: 
08/25/2011