Provider First Line Business Practice Location Address:
821 W PINE ST
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:
63901-4956
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-785-6434
Provider Business Practice Location Address Fax Number:
573-785-6435
Provider Enumeration Date:
03/24/2010