Provider First Line Business Practice Location Address:
2214 OSBORNE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUMBOLDT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38343-3044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-824-2742
Provider Business Practice Location Address Fax Number:
731-824-2743
Provider Enumeration Date:
04/06/2006