Provider First Line Business Practice Location Address:
2210 BARRON RD
Provider Second Line Business Practice Location Address:
SUITE 219
Provider Business Practice Location Address City Name:
POPLAR BLUFF
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63901-1908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-686-2811
Provider Business Practice Location Address Fax Number:
573-686-3441
Provider Enumeration Date:
11/27/2006