Provider First Line Business Practice Location Address:
1646 RUSSELL AVE
Provider Second Line Business Practice Location Address:
CARSON-NEWMAN COLLEGE
Provider Business Practice Location Address City Name:
JEFFERSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37760-2204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-471-4841
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/14/2005