Provider First Line Business Practice Location Address:
425 19TH STREET ENSLEY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35218-1601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-587-6569
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/19/2012