Provider First Line Business Practice Location Address: 
71A N. SECTION ST.
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FAIRHOPE
    Provider Business Practice Location Address State Name: 
AL
    Provider Business Practice Location Address Postal Code: 
36532
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
251-928-8221
    Provider Business Practice Location Address Fax Number: 
251-928-8229
    Provider Enumeration Date: 
02/23/2007