Provider First Line Business Practice Location Address:
3019 FAIR ST
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:
63901-7044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-778-9300
Provider Business Practice Location Address Fax Number:
573-778-9358
Provider Enumeration Date:
05/24/2007