Provider First Line Business Practice Location Address:
608 S HIGHWAY 65 82
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
LAKE VILLAGE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71653-1743
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-265-3711
Provider Business Practice Location Address Fax Number:
870-265-3707
Provider Enumeration Date:
02/25/2011