Provider First Line Business Practice Location Address:
1 PROFESSIONAL PARK DR
Provider Second Line Business Practice Location Address:
SUITE 21
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37604-6587
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-928-5111
Provider Business Practice Location Address Fax Number:
423-928-1174
Provider Enumeration Date:
08/11/2005