Provider First Line Business Practice Location Address: 
1913 E MAIN ST
    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: 
38343-3013
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
731-784-7200
    Provider Business Practice Location Address Fax Number: 
731-784-3826
    Provider Enumeration Date: 
05/10/2006