Provider First Line Business Practice Location Address:
321 E ELK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELIZABETHTON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37643-3221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-542-2512
Provider Business Practice Location Address Fax Number:
423-542-0477
Provider Enumeration Date:
10/24/2005