Provider First Line Business Practice Location Address: 
256 HONEYSUCKLE, SUITE 14
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DOTHAN
    Provider Business Practice Location Address State Name: 
AL
    Provider Business Practice Location Address Postal Code: 
36305
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
334-794-5467
    Provider Business Practice Location Address Fax Number: 
334-677-1051
    Provider Enumeration Date: 
10/03/2006