Provider First Line Business Practice Location Address:
2218 COLUMBIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRENTISS
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39474
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-792-2224
Provider Business Practice Location Address Fax Number:
601-792-2444
Provider Enumeration Date:
10/24/2006