Provider First Line Business Practice Location Address: 
108 SANDERS ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ATHENS
    Provider Business Practice Location Address State Name: 
AL
    Provider Business Practice Location Address Postal Code: 
35611-2459
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
256-232-0636
    Provider Business Practice Location Address Fax Number: 
256-232-1058
    Provider Enumeration Date: 
11/30/2006