Provider First Line Business Practice Location Address:
712 W WALNUT 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:
37604-6524
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-928-5500
Provider Business Practice Location Address Fax Number:
423-929-1505
Provider Enumeration Date:
01/26/2011