Provider First Line Business Practice Location Address:
138 HWY 270 EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT IDA
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71957-0901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-867-3432
Provider Business Practice Location Address Fax Number:
870-867-3783
Provider Enumeration Date:
12/19/2006