Provider First Line Business Practice Location Address:
2221 JACKSBORO PIKE
Provider Second Line Business Practice Location Address:
SUITE B1
Provider Business Practice Location Address City Name:
LAFOLLETTE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37766-3006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-566-2033
Provider Business Practice Location Address Fax Number:
423-566-9510
Provider Enumeration Date:
03/18/2010