Provider First Line Business Practice Location Address:
130 NORTH HIGH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHUBUTA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-687-1391
Provider Business Practice Location Address Fax Number:
601-687-0051
Provider Enumeration Date:
03/21/2007