Provider First Line Business Practice Location Address:
6178 E SHELBY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38141-7701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-310-4790
Provider Business Practice Location Address Fax Number:
901-310-4791
Provider Enumeration Date:
09/19/2025