Provider First Line Business Practice Location Address:
508 PRINCETON RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37601-2060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-384-0614
Provider Business Practice Location Address Fax Number:
423-928-5814
Provider Enumeration Date:
05/23/2007