Provider First Line Business Practice Location Address: 
1146 N BRINDLEE MOUNTAIN PKWY
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ARAB
    Provider Business Practice Location Address State Name: 
AL
    Provider Business Practice Location Address Postal Code: 
35016-1063
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
256-586-5322
    Provider Business Practice Location Address Fax Number: 
256-931-4277
    Provider Enumeration Date: 
09/20/2011