Provider First Line Business Practice Location Address: 
1400 HORNBROOK ST.
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DYERSBURG
    Provider Business Practice Location Address State Name: 
TN
    Provider Business Practice Location Address Postal Code: 
38024
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
731-286-7832
    Provider Business Practice Location Address Fax Number: 
731-286-7836
    Provider Enumeration Date: 
08/10/2023