Provider First Line Business Practice Location Address: 
601B MEDICAL CENTER PKWY
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BOAZ
    Provider Business Practice Location Address State Name: 
AL
    Provider Business Practice Location Address Postal Code: 
35957-5937
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
256-593-9070
    Provider Business Practice Location Address Fax Number: 
256-593-9071
    Provider Enumeration Date: 
05/10/2006