Provider First Line Business Practice Location Address:
1203 POPLAR AVE STE 5
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:
38104-7278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-728-5554
Provider Business Practice Location Address Fax Number:
901-728-6011
Provider Enumeration Date:
10/24/2006