Provider First Line Business Practice Location Address:
5249 HWY 67W
Provider Second Line Business Practice Location Address:
NORTHEAST CORRECTIONAL CENTER
Provider Business Practice Location Address City Name:
MOUNTAIN CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37683-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-727-7387
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/15/2010