Provider First Line Business Practice Location Address:
120 N WATAUGA LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOOKOUT MTN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37350-1356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-821-7508
Provider Business Practice Location Address Fax Number:
423-821-5432
Provider Enumeration Date:
11/15/2005