Provider First Line Business Practice Location Address: 
285 2ND AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DAYTON
    Provider Business Practice Location Address State Name: 
TN
    Provider Business Practice Location Address Postal Code: 
37321-1201
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
423-285-5888
    Provider Business Practice Location Address Fax Number: 
423-285-5901
    Provider Enumeration Date: 
07/31/2014