Provider First Line Business Practice Location Address:
164 OLD COSBY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37821-2998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-623-9540
Provider Business Practice Location Address Fax Number:
423-623-5465
Provider Enumeration Date:
01/03/2007