Provider First Line Business Practice Location Address:
1013 MEDICAL CENTER PKWY
Provider Second Line Business Practice Location Address:
BUILDING 1 SUITE A
Provider Business Practice Location Address City Name:
SELMA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36701-6742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-875-4374
Provider Business Practice Location Address Fax Number:
334-875-4340
Provider Enumeration Date:
10/25/2006