Provider First Line Business Practice Location Address:
6490 MOUNT MORIAH ROAD EXT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38115-3729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-367-1001
Provider Business Practice Location Address Fax Number:
901-565-0616
Provider Enumeration Date:
12/20/2006