Provider First Line Business Practice Location Address:
2636 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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-566-1967
Provider Business Practice Location Address Fax Number:
423-566-1797
Provider Enumeration Date:
04/10/2007