Provider First Line Business Practice Location Address: 
3623 FOUNTAIN AVE
    Provider Second Line Business Practice Location Address: 
APARTMENT 73
    Provider Business Practice Location Address City Name: 
EAST RIDGE
    Provider Business Practice Location Address State Name: 
TN
    Provider Business Practice Location Address Postal Code: 
37412-1846
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
423-954-8860
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/01/2007