Provider First Line Business Practice Location Address: 
615 MEADOWS DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BIRMINGHAM
    Provider Business Practice Location Address State Name: 
AL
    Provider Business Practice Location Address Postal Code: 
35235
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
205-276-5470
    Provider Business Practice Location Address Fax Number: 
205-655-1087
    Provider Enumeration Date: 
10/23/2012