Provider First Line Business Practice Location Address:
710 W ELLIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEFFERSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37760-2101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-312-5181
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/21/2007