Provider First Line Business Practice Location Address: 
220 TOM ELLSWORTH DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HOT SPRINGS
    Provider Business Practice Location Address State Name: 
AR
    Provider Business Practice Location Address Postal Code: 
71901-3140
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
501-620-7841
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/15/2014