Provider First Line Business Practice Location Address: 
101 OKLAHOMA AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MCALESTER
    Provider Business Practice Location Address State Name: 
OK
    Provider Business Practice Location Address Postal Code: 
74501-7520
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
580-298-9818
    Provider Business Practice Location Address Fax Number: 
580-298-9822
    Provider Enumeration Date: 
08/31/2009