Provider First Line Business Practice Location Address:
607 BAXTER ST
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:
37601-4003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-232-2760
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/08/2008