Provider First Line Business Practice Location Address:
133 SCANLAN ST
Provider Second Line Business Practice Location Address:
LA-Z-BOY SOUTH CLINIC
Provider Business Practice Location Address City Name:
NEWTON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39345-2329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-683-1375
Provider Business Practice Location Address Fax Number:
601-683-4120
Provider Enumeration Date:
11/13/2006