Provider First Line Business Practice Location Address:
527 DESOTO AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARKSDALE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-627-2565
Provider Business Practice Location Address Fax Number:
662-627-2524
Provider Enumeration Date:
12/18/2006