Provider First Line Business Practice Location Address: 
4850 E ANDREW JOHNSON HWY
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GREENEVILLE
    Provider Business Practice Location Address State Name: 
TN
    Provider Business Practice Location Address Postal Code: 
37745-3098
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
423-798-6265
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/08/2011