Provider First Line Business Practice Location Address:
2400 E MITCHELL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUMBOLDT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38343-3036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-784-5183
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/30/2010