Provider First Line Business Practice Location Address: 
1280 HUEYTOWN RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HUEYTOWN
    Provider Business Practice Location Address State Name: 
AL
    Provider Business Practice Location Address Postal Code: 
35023-2602
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
205-491-2805
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/16/2007