Provider First Line Business Practice Location Address:
8950 HWY 64
Provider Second Line Business Practice Location Address:
SUITE 116
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-383-7170
Provider Business Practice Location Address Fax Number:
901-388-6478
Provider Enumeration Date:
08/30/2005