Provider First Line Business Practice Location Address:
BOX 1798 DEPT 07-49
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:
38101-9715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-476-1313
Provider Business Practice Location Address Fax Number:
901-476-1314
Provider Enumeration Date:
06/24/2005