Provider First Line Business Practice Location Address:
807 UNIVERSITY PKWY
Provider Second Line Business Practice Location Address:
MAPLE AVENUE, BUILDING 7, SUITE 312
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37614-6500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-439-6742
Provider Business Practice Location Address Fax Number:
423-439-6784
Provider Enumeration Date:
11/21/2012