Provider First Line Business Practice Location Address:
400 US HIGHWAY 45 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUMBOLDT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38343-8503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-784-0042
Provider Business Practice Location Address Fax Number:
731-784-8868
Provider Enumeration Date:
11/29/2011