Provider First Line Business Practice Location Address:
149 N 12TH AVE
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:
38343-2879
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-784-5491
Provider Business Practice Location Address Fax Number:
731-784-1726
Provider Enumeration Date:
02/21/2007