Provider First Line Business Practice Location Address:
2400 LUCY LEE PKWY STE F
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:
63901-2427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-609-2266
Provider Business Practice Location Address Fax Number:
573-785-0974
Provider Enumeration Date:
11/30/2006