Provider First Line Business Practice Location Address:
1282 UNION AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38104-3414
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-822-7454
Provider Business Practice Location Address Fax Number:
866-353-7575
Provider Enumeration Date:
10/23/2007