Provider First Line Business Practice Location Address:
312 ELLIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARTHAGE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-267-6856
Provider Business Practice Location Address Fax Number:
601-267-6859
Provider Enumeration Date:
05/24/2006