Provider First Line Business Practice Location Address:
4358 HIGHWAY PP
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:
63901-1552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-686-5439
Provider Business Practice Location Address Fax Number:
573-778-0103
Provider Enumeration Date:
05/23/2011