Provider First Line Business Practice Location Address:
2865 E MAIN ST
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:
38343-3070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-784-8405
Provider Business Practice Location Address Fax Number:
731-784-2448
Provider Enumeration Date:
08/25/2005