Provider First Line Business Practice Location Address:
130 W RAVINE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37660-3837
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-224-3628
Provider Business Practice Location Address Fax Number:
423-230-8502
Provider Enumeration Date:
12/28/2005