Provider First Line Business Practice Location Address: 
1557 3RD ST NE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CULLMAN
    Provider Business Practice Location Address State Name: 
AL
    Provider Business Practice Location Address Postal Code: 
35055-2053
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
256-734-2325
    Provider Business Practice Location Address Fax Number: 
256-734-2320
    Provider Enumeration Date: 
09/20/2005