Provider First Line Business Practice Location Address: 
2160 MOORES MILL RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
AUBURN
    Provider Business Practice Location Address State Name: 
AL
    Provider Business Practice Location Address Postal Code: 
36830-8487
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
334-524-8300
    Provider Business Practice Location Address Fax Number: 
901-922-5447
    Provider Enumeration Date: 
07/24/2014