Provider First Line Business Practice Location Address:
104 B WEST OLD AJ HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEFFERSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37760-0287
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-471-1460
Provider Business Practice Location Address Fax Number:
865-471-1460
Provider Enumeration Date:
10/24/2006