Provider First Line Business Practice Location Address:
501 E WATAUGA 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:
37601-4038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-722-8446
Provider Business Practice Location Address Fax Number:
423-722-5674
Provider Enumeration Date:
12/19/2005