Provider First Line Business Practice Location Address:
1801 E 4TH ST
Provider Second Line Business Practice Location Address:
LACKEY HALL SOUTH
Provider Business Practice Location Address City Name:
OKMULGEE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74447-3942
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-756-3334
Provider Business Practice Location Address Fax Number:
918-756-3993
Provider Enumeration Date:
07/30/2006