Provider First Line Business Practice Location Address: 
1130 QUINTARD AVE,
    Provider Second Line Business Practice Location Address: 
SUITE 501 QUINTARD TOWER
    Provider Business Practice Location Address City Name: 
ANNISTON
    Provider Business Practice Location Address State Name: 
AL
    Provider Business Practice Location Address Postal Code: 
36201-4689
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
256-237-6685
    Provider Business Practice Location Address Fax Number: 
256-237-6686
    Provider Enumeration Date: 
09/06/2012