Provider First Line Business Practice Location Address: 
2485 FORT CAMPBELL BLVD
    Provider Second Line Business Practice Location Address: 
STE 101
    Provider Business Practice Location Address City Name: 
CLARKSVILLE
    Provider Business Practice Location Address State Name: 
TN
    Provider Business Practice Location Address Postal Code: 
37042
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
931-431-0200
    Provider Business Practice Location Address Fax Number: 
931-431-3022
    Provider Enumeration Date: 
11/30/2006