Provider First Line Business Practice Location Address: 
120 S 4TH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HEBER SPRINGS
    Provider Business Practice Location Address State Name: 
AR
    Provider Business Practice Location Address Postal Code: 
72543-3810
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
501-362-5853
    Provider Business Practice Location Address Fax Number: 
501-500-6380
    Provider Enumeration Date: 
01/13/2021