Provider First Line Business Practice Location Address: 
1000 BB KING RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
INDIANOLA
    Provider Business Practice Location Address State Name: 
MS
    Provider Business Practice Location Address Postal Code: 
38751-3606
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
662-887-3000
    Provider Business Practice Location Address Fax Number: 
662-887-3500
    Provider Enumeration Date: 
08/19/2011