Provider First Line Business Practice Location Address:
2205 JACKSBORO PK
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFOLLETTE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-352-6500
Provider Business Practice Location Address Fax Number:
423-352-6501
Provider Enumeration Date:
10/19/2006