Provider First Line Business Practice Location Address:
625 E 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH PITTSBURG
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37380-1630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-648-4460
Provider Business Practice Location Address Fax Number:
423-648-4461
Provider Enumeration Date:
06/15/2006