Provider First Line Business Practice Location Address:
449 S HWY 53
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:
63901-7204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-686-1919
Provider Business Practice Location Address Fax Number:
573-686-8450
Provider Enumeration Date:
08/18/2006