Provider First Line Business Practice Location Address:
110 BAKER AVE
Provider Second Line Business Practice Location Address:
P.O. DRAWER 1200
Provider Business Practice Location Address City Name:
CLANTON
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35045-2337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-280-6450
Provider Business Practice Location Address Fax Number:
205-280-6451
Provider Enumeration Date:
07/12/2006