Provider First Line Business Practice Location Address:
119 INGRAM STREET
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
CLINTON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-745-8881
Provider Business Practice Location Address Fax Number:
501-745-3113
Provider Enumeration Date:
10/20/2006