Provider First Line Business Practice Location Address: 
UNIVERSITY OF CENTRAL ARKANSAS
    Provider Second Line Business Practice Location Address: 
PRINCE CENTER - ROOM 133C
    Provider Business Practice Location Address City Name: 
CONWAY
    Provider Business Practice Location Address State Name: 
AR
    Provider Business Practice Location Address Postal Code: 
72035-0001
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
501-450-5106
    Provider Business Practice Location Address Fax Number: 
501-450-5087
    Provider Enumeration Date: 
04/07/2006