Provider First Line Business Practice Location Address:
1161 21ST STREET SOUTH
Provider Second Line Business Practice Location Address:
SUITE T-1218 MCN, VANDERBILT UNIVERSITY MEDICAL CENTER
Provider Business Practice Location Address City Name:
NASHVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37232-2650
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-322-3412
Provider Business Practice Location Address Fax Number:
615-322-2582
Provider Enumeration Date:
11/25/2005