Provider First Line Business Practice Location Address: 
121 N 20TH ST # 2
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
OPELIKA
    Provider Business Practice Location Address State Name: 
AL
    Provider Business Practice Location Address Postal Code: 
36801-5449
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
334-745-6447
    Provider Business Practice Location Address Fax Number: 
334-742-0713
    Provider Enumeration Date: 
06/30/2011