Provider First Line Business Practice Location Address:
2600 STATE LINE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELIZABETHTON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37643-7204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-542-4245
Provider Business Practice Location Address Fax Number:
423-542-4369
Provider Enumeration Date:
09/12/2007