Provider First Line Business Practice Location Address:
9160 HIGHWAY 64
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38002-4766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-388-4474
Provider Business Practice Location Address Fax Number:
901-388-4486
Provider Enumeration Date:
06/15/2007