Provider First Line Business Practice Location Address:
1617 N MAIN ST.
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-778-3042
Provider Business Practice Location Address Fax Number:
573-778-9432
Provider Enumeration Date:
10/02/2006