Provider First Line Business Practice Location Address:
22 COUNTY ROAD 445
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:
63901-1530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-718-2279
Provider Business Practice Location Address Fax Number:
573-785-3966
Provider Enumeration Date:
04/19/2006