Provider First Line Business Practice Location Address: 
112 BOONEWOOD PRIVATE DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PINEY FLATS
    Provider Business Practice Location Address State Name: 
TN
    Provider Business Practice Location Address Postal Code: 
37686-3611
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
423-335-6047
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/30/2006