Provider First Line Business Practice Location Address: 
1413 W QUITMAN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
IUKA
    Provider Business Practice Location Address State Name: 
MS
    Provider Business Practice Location Address Postal Code: 
38852
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
662-424-9550
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/14/2007