Provider First Line Business Practice Location Address:
1301 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:
38343-3327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-784-4748
Provider Business Practice Location Address Fax Number:
731-784-6838
Provider Enumeration Date:
11/17/2006