Provider First Line Business Practice Location Address: 
2648 MOUNT OLIVE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MOUNT OLIVE
    Provider Business Practice Location Address State Name: 
AL
    Provider Business Practice Location Address Postal Code: 
35117-3925
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
205-631-1201
    Provider Business Practice Location Address Fax Number: 
205-608-1596
    Provider Enumeration Date: 
12/06/2005