Provider First Line Business Practice Location Address:
562 LINE ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39350-2144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-656-0340
Provider Business Practice Location Address Fax Number:
601-656-0342
Provider Enumeration Date:
10/20/2010