Provider First Line Business Practice Location Address: 
75 OLD HWY 98 E
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
TYLERTOWN
    Provider Business Practice Location Address State Name: 
MS
    Provider Business Practice Location Address Postal Code: 
39667
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
601-876-2176
    Provider Business Practice Location Address Fax Number: 
601-876-4513
    Provider Enumeration Date: 
03/26/2007