Provider First Line Business Practice Location Address:
6099 MT MORIAH RD EXT
Provider Second Line Business Practice Location Address:
SUITE 18
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38115-0313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-729-7680
Provider Business Practice Location Address Fax Number:
901-729-7683
Provider Enumeration Date:
12/18/2013