Provider First Line Business Practice Location Address:
RR 2 BOX 1755
Provider Second Line Business Practice Location Address:
HWY 63A N PASSED VO TECH 1 MILE
Provider Business Practice Location Address City Name:
TALIHINA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74571-9517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-567-4250
Provider Business Practice Location Address Fax Number:
918-567-2087
Provider Enumeration Date:
08/12/2006