Provider First Line Business Practice Location Address:
1616 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:
38343-2904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-784-3610
Provider Business Practice Location Address Fax Number:
731-784-9989
Provider Enumeration Date:
05/09/2007