Provider First Line Business Practice Location Address:
1720 KANELL BLVD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
POPLAR BLUFF
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63901-4009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-778-1336
Provider Business Practice Location Address Fax Number:
573-778-1336
Provider Enumeration Date:
08/15/2006