Provider First Line Business Practice Location Address:
712 S MOORE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST RIDGE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37412-2954
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-304-1885
Provider Business Practice Location Address Fax Number:
423-591-5911
Provider Enumeration Date:
02/08/2010