Provider First Line Business Practice Location Address: 
590 MEDICAL CENTER DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FORT PAYNE
    Provider Business Practice Location Address State Name: 
AL
    Provider Business Practice Location Address Postal Code: 
35968
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
256-997-2526
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
05/05/2009