Provider First Line Business Practice Location Address: 
1637 NIGGS CREEK RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ONEIDA
    Provider Business Practice Location Address State Name: 
TN
    Provider Business Practice Location Address Postal Code: 
37841-6417
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
423-215-3044
    Provider Business Practice Location Address Fax Number: 
423-286-9095
    Provider Enumeration Date: 
02/21/2008