Provider First Line Business Practice Location Address:
511 CEDAR 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:
63901-7301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-686-2333
Provider Business Practice Location Address Fax Number:
573-686-1641
Provider Enumeration Date:
11/20/2006