Provider First Line Business Practice Location Address: 
1715 N JACKSON ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
TULLAHOMA
    Provider Business Practice Location Address State Name: 
TN
    Provider Business Practice Location Address Postal Code: 
37388-2231
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
615-673-6737
    Provider Business Practice Location Address Fax Number: 
800-474-4039
    Provider Enumeration Date: 
06/30/2012