Provider First Line Business Practice Location Address: 
5700 S ZERO ST
    Provider Second Line Business Practice Location Address: 
STE. 2
    Provider Business Practice Location Address City Name: 
FORT SMITH
    Provider Business Practice Location Address State Name: 
AR
    Provider Business Practice Location Address Postal Code: 
72903-6505
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
479-649-6464
    Provider Business Practice Location Address Fax Number: 
479-649-6565
    Provider Enumeration Date: 
07/19/2005