Provider First Line Business Practice Location Address:
6099 MOUNT MORIAH ROAD EXT
Provider Second Line Business Practice Location Address:
SUITE 21
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38115-0313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-746-8966
Provider Business Practice Location Address Fax Number:
901-746-8989
Provider Enumeration Date:
03/08/2011