Provider First Line Business Practice Location Address:
100 E MAPLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37601-6816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-622-1551
Provider Business Practice Location Address Fax Number:
877-856-7133
Provider Enumeration Date:
09/29/2026