Provider First Line Business Practice Location Address:
1630 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUMBOLDT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-784-3143
Provider Business Practice Location Address Fax Number:
731-784-7979
Provider Enumeration Date:
11/16/2006