Provider First Line Business Practice Location Address:
CORNER OF SIDNEY AND LAMONT STREET
Provider Second Line Business Practice Location Address:
BUILDING 161, NHCU-2
Provider Business Practice Location Address City Name:
MOUNTAIN HOME
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37684
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-926-1171
Provider Business Practice Location Address Fax Number:
423-979-3437
Provider Enumeration Date:
10/23/2006