Provider First Line Business Practice Location Address: 
1112 GENE REED RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BIRMINGHAM
    Provider Business Practice Location Address State Name: 
AL
    Provider Business Practice Location Address Postal Code: 
35235-2405
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
205-836-8691
    Provider Business Practice Location Address Fax Number: 
205-836-8170
    Provider Enumeration Date: 
07/12/2006