Provider First Line Business Practice Location Address:
1307 WOODLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37601-2633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-773-7713
Provider Business Practice Location Address Fax Number:
423-202-7882
Provider Enumeration Date:
06/30/2009