Provider First Line Business Practice Location Address:
1116 20TH ST.
Provider Second Line Business Practice Location Address:
PMB 20
Provider Business Practice Location Address City Name:
BIRMINGTON
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35205-2612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-323-8732
Provider Business Practice Location Address Fax Number:
520-547-1865
Provider Enumeration Date:
01/31/2008