Provider First Line Business Practice Location Address:
8950 US HIGHWAY 64
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38002-4566
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-213-0100
Provider Business Practice Location Address Fax Number:
901-213-0101
Provider Enumeration Date:
11/05/2013