Provider First Line Business Practice Location Address: 
239 CHURCH ST
    Provider Second Line Business Practice Location Address: 
SUITE B
    Provider Business Practice Location Address City Name: 
ALEXANDER CITY
    Provider Business Practice Location Address State Name: 
AL
    Provider Business Practice Location Address Postal Code: 
35010-2512
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
256-392-4400
    Provider Business Practice Location Address Fax Number: 
256-392-4402
    Provider Enumeration Date: 
07/07/2011