Provider First Line Business Practice Location Address:
725 HIGHWAY 142
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:
63901-8159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-598-8733
Provider Business Practice Location Address Fax Number:
573-312-3767
Provider Enumeration Date:
11/26/2007