Provider First Line Business Practice Location Address:
256 S CAMILLA ST
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:
38104-3335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-528-1284
Provider Business Practice Location Address Fax Number:
901-528-1289
Provider Enumeration Date:
05/16/2006