Provider First Line Business Practice Location Address:
110 E MOUNTCASTLE DR
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37601-2539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-928-7770
Provider Business Practice Location Address Fax Number:
423-283-0433
Provider Enumeration Date:
08/04/2006