Provider First Line Business Practice Location Address: 
340 S 2ND ST
    Provider Second Line Business Practice Location Address: 
SUITE 8
    Provider Business Practice Location Address City Name: 
GADSDEN
    Provider Business Practice Location Address State Name: 
AL
    Provider Business Practice Location Address Postal Code: 
35901-5201
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
256-547-4407
    Provider Business Practice Location Address Fax Number: 
256-547-4439
    Provider Enumeration Date: 
11/01/2006