Provider First Line Business Practice Location Address:
10001 CASA REAL CV
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37922-4183
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-712-7689
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/20/2025