Provider First Line Business Practice Location Address:
5439 LEXIE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38116-9010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-491-9132
Provider Business Practice Location Address Fax Number:
901-205-0505
Provider Enumeration Date:
10/08/2025