Provider First Line Business Practice Location Address:
1110 15TH ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
TUSCALOOSA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35401-3392
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-758-0053
Provider Business Practice Location Address Fax Number:
205-758-0390
Provider Enumeration Date:
08/20/2007