Provider First Line Business Practice Location Address:
2145 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:
37766-3003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-562-1531
Provider Business Practice Location Address Fax Number:
423-562-1724
Provider Enumeration Date:
05/10/2007