Provider First Line Business Practice Location Address: 
601 LEIGHTON AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ANNISTON
    Provider Business Practice Location Address State Name: 
AL
    Provider Business Practice Location Address Postal Code: 
36207-5743
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
256-240-7332
    Provider Business Practice Location Address Fax Number: 
256-240-7334
    Provider Enumeration Date: 
02/08/2011