Provider First Line Business Practice Location Address: 
6000 TROTWOOD AVENUE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
COLUMBIA
    Provider Business Practice Location Address State Name: 
TN
    Provider Business Practice Location Address Postal Code: 
38401-3527
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
931-381-9721
    Provider Business Practice Location Address Fax Number: 
931-381-3507
    Provider Enumeration Date: 
10/04/2006