Provider First Line Business Practice Location Address:
619 19TH STREET SOUTH
Provider Second Line Business Practice Location Address:
P915
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35294
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-975-0512
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/18/2010