Provider First Line Business Practice Location Address:
6490 MOUNT MORIAH ROAD EXT STE 201
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:
38115-3841
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-366-2168
Provider Business Practice Location Address Fax Number:
901-366-2169
Provider Enumeration Date:
09/21/2009