**Exhibit      10.4**

**FIRST      AMENDMENT TO LEASE AGREEMENT**

**BURTON      HILLS IV PARTNERS**
**CHD      MERIDIAN HEALTHCARE, LLC**
**CHD      Meridian Healthcare, LLC **
**Meridian      Occupational Healthcare Associates, Inc.**
** **

| 1.   | Revision                of Basic Lease Provisions.                The Original Lease is hereby amended and restated as follows, with                these                amendments  taking effect on the later of July 1, 2005, or upon                delivery of the expansion space, and to be documented in a Commencement                Letter Agreement, Section 1.02 of the Original Lease shall be deemed                amended and restated as follows: |
|----------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

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|  A. | Building              Name:   | Burton              Hills              IV |   |
|----------|-----------------------------------------|-------------------------------------------|--------|
|     | Address:                                | 40                Burton Hills Boulevard  |   |
|     |                                    | Nashville,                TN 37215        |   |

| B.   | Rentable                Area of Leased Premises: 30,922 square                feet; |
|----------------|-------------------------------------------------------------------------------------|

| C.   | Building                Expense Percentage: 22.91%                (30,922/135,000); |
|----------------|-------------------------------------------------------------------------------------|

| D.   | Minimum                Annual Rent: |
|----------------|-------------------------------------|

| Lease                Year (Months)                                                                                                                                                                                                                                                                                                | Base                Rate                                                                                         | Minimum                Annual Rental                                                                            |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------|
|  1                (12/1/02-11/30/03)2                (12/1/03-11/30/04)3                (12/1/04-06/30/05)3                (07/1/05-11/30/05)4                (12/1/05-11/30/06)5                (12/1/06-11/30/07)6                (12/1/07-11/30/08)7                (12/1/08-11/30/09)8                (12/1/09-06/30/10) |  $11.00/RSF                $24.00/RSF$24.00/RSF$24.00/RSF$26.00/RSF$26.00/RSF$27.00/RSF$27.00/RSF$27.00/RSF |  $292,006.00$637,104.00$371,644.00*$309,220.00**$803,972.00$803,972.00$834,894.00$834,894.00$487,021.50*** |

| E.   | Monthly                Rental Installments: |
|----------------|---------------------------------------------|

| Months                                                                                                                                                                                                                                                                                                                                                                           | Monthly                Rental Installments                                                       |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------|
|  1-12                (12/1/02-11/30/03)13-24                (12/1/03-11/30/04)25-31                (12/1/04-06/30/05)32-36                (07/1/05-11/30/05)37-48                (12/1/05-11/30/06) 49-60                (12/1/06-11/30/07)61-72                (12/1/07-11/30/08)73-84                (12/1/08-11/30/09)85-91                (12/1/09-06/30/10)  |  $24,333.83$53,092.00$53,092.00$61,844.00$66,997.67$66,997.67$69,574.50$69,574.50$69,574.50 |

| F.   | Term:                Seven (7) years and seven (7) months (December 1, 2002 through June                30,                2010); |
|----------------|-----------------------------------------------------------------------------------------------------------------------------------|

| G.   | Commencement                Date: December 1, 2002; |
|----------------|-----------------------------------------------------|

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| H.   | Security                Deposit: $36,204.00 is payable as the security deposit, and is due                upon                execution of this Lease. See Article 4 for requirements for                refund. |
|----------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

| I.   | Brokers:                Alex S. Palmer & Company, as Landlord’s                Broker; |
|----------------|--------------------------------------------------------------------------------------------------|

| J.   | Permitted                Use: General office purposes; |
|----------------|--------------------------------------------------------|

| K.   | Space                Plan Approval Date: March 1, 2002 (See Exhibit                B); |
|----------------|----------------------------------------------------------------------------------------|

| L.   | Options:                One (1) Five-Year Extension Option (See Section 2.07); |
|----------------|--------------------------------------------------------------------------------|

| M.   | Expiration                Date: June 30, 2010; |
|----------------|------------------------------------------------|

| N.   | Address                for payments and notices: |
|----------------|--------------------------------------------------|

|   | Landlord: | Burton                Hills IV Partners         |
|--------|-----------|-------------------------------------------------|
|   |      | c/o                Alex S. Palmer & Company |
|   |      | Palmer                Plaza, Suite 1600         |
|   |      | 1801                West End Avenue             |
|   |      | Nashville,                TN 37203              |
|   |      |                                            |
|   |      |                                            |
|   | Tenant:   | CHD                Meridian HealthCare          |
|   |      | Burton                Hills IV Office Building  |
|   |      | 40                Burton Hills Boulevard,       |
|   |      | Suite                200                        |
|   |      | Nashville,                TN 37215              |

| O.   | Delinquency                Interest Rate: An annual percentage rate of interest equal to three                percentage points (3%) in excess of the "Prime Rate" from time to                time                published in the Money Rates section of The Wall Street Journal,                which                rate as published on the last publication day in any month shall                be deemed                to be the appropriate reference rate for the entire next succeeding                calendar month; provided, however, that in no event shall the Delinquency                Interest Rate exceed the maximum contract rate of interest from time                to                time allowed to be charged under applicable law. Should The Wall                Street                Journal cease publication of its Prime Rate, the Landlord shall have                the                right to designate a comparable reference                rate. |
|----------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

| P.   | Lease                Month: The calendar month or partial calendar month in which the                Commencement Date occurs, and each subsequent calendar month during                the                Term. |
|----------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

| Q.   | Lease                Year: The period ending on the last day of the twelfth (12th)                month after the month in which the Commencement Date occurs, and                the                successive annual period(s), if any, ending on each subsequent anniversary                of said date. |
|----------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

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| 2.   | Build-Out                and Allowance for Additional Space.                Notwithstanding any provision to the contrary in the Lease or in                the Work                Letter Agreement attached as Exhibit F to the Original Lease, Landlord                shall cause the Landlord’s Contractor to construct the tenant improvements                for the Additional Space in accordance with plans and specifications                approved by Landlord and Tenant, Landlord shall be obligated to provide                an                allowance (the “Additional Space Allowance”) of only $22.00 per rentable                square foot for the 4,376 rentable square feet of Additional Space                added                to the Leased Premises by this First Amendment (in lieu of the Turnkey                Allowance provided for in the Original Lease), Tenant shall be obligated                to pay all costs incurred by Landlord or Landlord’s Contractor in excess                of such Additional Space Allowance, and the Lease and Work Letter                Agreement are hereby amended in all respects to incorporate the foregoing                terms. |
|----------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

| 3.   | Additional                Space Added to Leased Premises.                From and after July 1, 2005, all references to Leased Premises in                the                Original Lease shall be deemed to include the Additional Space, and                Exhibit A-2 to the Original Lease shall be deemed to be amended to                include                the Additional Space as depicted on Exhibit A attached                hereto. |
|----------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

| 4.   | Controlling                Provisions.                To the extent the provisions of this First Amendment are inconsistent                with                the Original Lease, the terms of this First Amendment shall                control. |
|----------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

| 5.   | Authority.                Landlord and Tenant affirm and covenant that each has the authority                to                enter into this First Amendment and to abide by the terms hereof,                and that                the signatories hereto are authorized representatives of their respective                entities empowered by their respective entities to execute this First                Amendment. |
|----------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

| 6.   | Force                and Effect.                Except as if expressly amended and modified herein, all other terms,                covenants and conditions of the Original Lease shall remain in full                force                and effect. |
|----------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

| 7.   | Successors                and Assigns.                The conditions, covenants and agreements contained herein shall be                binding                upon the parties hereto and their respective successors and                assigns. |
|----------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

| 8.   | Right                Of First Offer.                Tenant shall have the following expansion                right: |
|----------------|---------------------------------------------------------------------------------------------------------------------|

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|   | LANDLORD:                                       |                                        |
|--------|-------------------------------------------------|---------------------------------------------|
|   |                                            |                                        |
|   | **BURTON                HILLS IV PARTNERS**     |
|   |                                            |                                        |
|   | By:                                             | /s/                Dale Holmer, CFO/Partner |
|   | In                lieu of                       | Alex                S. Palmer,              |
|   |                                            | Managing                General Partner     |
|   |                                            |                                        |
|   |                                            |                                        |
|   | TENANT:                                         |                                        |
|   |                                            |                                        |
|   | **CHD                MERIDIAN HEALTHCARE, LLC** |
|   |                                            |                                        |
|   | By:                                             | /s/Tammy                Howell              |
|   |                                            |                                        |
|   | Title:                                          | Vice                President               |

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**BURTON      HILLS IV PARTNERS**

|   | illegible                    |
|--------|------------------------------|
|   | Notary                Public |

**CHD      MERIDIAN HEALTHCARE, LLC, **

|   | illegible                    |
|--------|------------------------------|
|   | Notary                Public |

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