Provider First Line Business Practice Location Address: 
611 E GLENN AVE
    Provider Second Line Business Practice Location Address: 
SUITE C
    Provider Business Practice Location Address City Name: 
AUBURN
    Provider Business Practice Location Address State Name: 
AL
    Provider Business Practice Location Address Postal Code: 
36830-4402
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
334-539-5140
    Provider Business Practice Location Address Fax Number: 
334-539-5141
    Provider Enumeration Date: 
12/05/2016