Provider First Line Business Practice Location Address: 
5401 E LAKE BLVD
    Provider Second Line Business Practice Location Address: 
117MDG
    Provider Business Practice Location Address City Name: 
BIRMINGHAM
    Provider Business Practice Location Address State Name: 
AL
    Provider Business Practice Location Address Postal Code: 
35217-3545
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
205-714-2213
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/10/2006