Provider First Line Business Practice Location Address:
1611 LURLYN DR STE A
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:
63901-2763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-778-0200
Provider Business Practice Location Address Fax Number:
573-778-0214
Provider Enumeration Date:
08/25/2006