Provider First Line Business Practice Location Address:
112 NORTH 3RD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKEMAH
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74859-2602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-382-4939
Provider Business Practice Location Address Fax Number:
405-382-4947
Provider Enumeration Date:
05/22/2006