Provider First Line Business Practice Location Address:
2406 SUSANNAH ST
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:
37601-1725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-282-2542
Provider Business Practice Location Address Fax Number:
423-282-5447
Provider Enumeration Date:
04/10/2007