Provider First Line Business Practice Location Address:
2716 N CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUMBOLDT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38343-1560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-784-9409
Provider Business Practice Location Address Fax Number:
731-784-9418
Provider Enumeration Date:
07/16/2010