Provider First Line Business Practice Location Address: 
100B4 GT THAMES DRIVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
STARKVILLE
    Provider Business Practice Location Address State Name: 
MS
    Provider Business Practice Location Address Postal Code: 
39759
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
662-615-1870
    Provider Business Practice Location Address Fax Number: 
662-615-1871
    Provider Enumeration Date: 
09/19/2012