Provider First Line Business Practice Location Address:
1203 POPLAR AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38104-7241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-274-3550
Provider Business Practice Location Address Fax Number:
901-274-3551
Provider Enumeration Date:
02/16/2010