Provider First Line Business Practice Location Address: 
2000 HIGHWAY 25B
    Provider Second Line Business Practice Location Address: 
SUITE A-1
    Provider Business Practice Location Address City Name: 
HEBER SPRINGS
    Provider Business Practice Location Address State Name: 
AR
    Provider Business Practice Location Address Postal Code: 
72543-6417
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
501-362-7195
    Provider Business Practice Location Address Fax Number: 
501-362-7855
    Provider Enumeration Date: 
12/10/2014