Provider First Line Business Practice Location Address: 
3300 CLIFF DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FORT SMITH
    Provider Business Practice Location Address State Name: 
AR
    Provider Business Practice Location Address Postal Code: 
72903-5917
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
479-651-4314
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/09/2011