Provider First Line Business Practice Location Address: 
214 LAKEVIEW RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SOMERVILLE
    Provider Business Practice Location Address State Name: 
TN
    Provider Business Practice Location Address Postal Code: 
38068-9737
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
901-516-4000
    Provider Business Practice Location Address Fax Number: 
205-313-5245
    Provider Enumeration Date: 
10/28/2008