Provider First Line Business Practice Location Address:
17 SO. LOGAN ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72933
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-965-7702
Provider Business Practice Location Address Fax Number:
479-965-2180
Provider Enumeration Date:
03/19/2008