Provider First Line Business Practice Location Address:
621 W PINE 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:
63901-5042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-686-8199
Provider Business Practice Location Address Fax Number:
573-686-8398
Provider Enumeration Date:
04/20/2006