Provider First Line Business Practice Location Address: 
2552 S CHURCH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MURFREESBORO
    Provider Business Practice Location Address State Name: 
TN
    Provider Business Practice Location Address Postal Code: 
37127-7135
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
615-893-2313
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/27/2014