Provider First Line Business Practice Location Address:
1 PROFESSIONAL PARK DR
Provider Second Line Business Practice Location Address:
MCPP #1, SUITE 18
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37604-6587
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-926-0063
Provider Business Practice Location Address Fax Number:
423-926-0073
Provider Enumeration Date:
02/01/2006