Provider First Line Business Practice Location Address:
1014 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:
63901-4840
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-785-8421
Provider Business Practice Location Address Fax Number:
573-785-3348
Provider Enumeration Date:
05/23/2007