Provider First Line Business Practice Location Address:
1310 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUMBOLDT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38343-3328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-803-8255
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/31/2011