Provider First Line Business Practice Location Address: 
430 GREEN SPRINGS HWY
    Provider Second Line Business Practice Location Address: 
SUITE 21
    Provider Business Practice Location Address City Name: 
HOMEWOOD
    Provider Business Practice Location Address State Name: 
AL
    Provider Business Practice Location Address Postal Code: 
35209-4945
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
205-290-0021
    Provider Business Practice Location Address Fax Number: 
205-290-2187
    Provider Enumeration Date: 
08/10/2007