Provider First Line Business Practice Location Address:
1174 POPLAR AVENUE
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:
38105-4805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-278-1412
Provider Business Practice Location Address Fax Number:
901-278-6972
Provider Enumeration Date:
06/26/2007