Provider First Line Business Practice Location Address:
1211 21ST AVE SOUTH
Provider Second Line Business Practice Location Address:
MEDICAL ARTS BLDG., ROOM 701
Provider Business Practice Location Address City Name:
NASHVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37212-1050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-936-1595
Provider Business Practice Location Address Fax Number:
615-343-7246
Provider Enumeration Date:
10/25/2005