Provider First Line Business Practice Location Address:
2212 JACKSBORO PIKE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA FOLLETTE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37766-2903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-201-9287
Provider Business Practice Location Address Fax Number:
423-201-9290
Provider Enumeration Date:
11/30/2012