Provider First Line Business Practice Location Address:
111 W FAIRVIEW AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37604-5632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-929-8011
Provider Business Practice Location Address Fax Number:
429-929-7811
Provider Enumeration Date:
09/23/2005