Provider First Line Business Practice Location Address:
3950 CENTRAL 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:
38111-7602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-458-6291
Provider Business Practice Location Address Fax Number:
901-323-4848
Provider Enumeration Date:
07/27/2005