Provider First Line Business Practice Location Address: 
5078 CLINTON HWY
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
KNOXVILLE
    Provider Business Practice Location Address State Name: 
TN
    Provider Business Practice Location Address Postal Code: 
37912-3953
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
865-689-8955
    Provider Business Practice Location Address Fax Number: 
865-689-9484
    Provider Enumeration Date: 
06/10/2015