Provider First Line Business Practice Location Address: 
4719 BRAINERD RD
    Provider Second Line Business Practice Location Address: 
SUITE C
    Provider Business Practice Location Address City Name: 
CHATTANOOGA
    Provider Business Practice Location Address State Name: 
TN
    Provider Business Practice Location Address Postal Code: 
37411-3830
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
423-629-9800
    Provider Business Practice Location Address Fax Number: 
423-629-4218
    Provider Enumeration Date: 
04/09/2007