Provider First Line Business Practice Location Address: 
115 DYER ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
COLUMBIA
    Provider Business Practice Location Address State Name: 
TN
    Provider Business Practice Location Address Postal Code: 
38401-4551
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
931-560-4241
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/07/2007