Provider First Line Business Practice Location Address:
1200 SPRUCE LN
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:
37643-4301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-543-3202
Provider Business Practice Location Address Fax Number:
423-543-6249
Provider Enumeration Date:
10/30/2012