Provider First Line Business Practice Location Address: 
4593 SWINNEA RD
    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: 
38118-7101
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
442-456-5387
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/07/2011