Provider First Line Business Practice Location Address:
336 W OLD ANDREW JOHNSON HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEFFERSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37760-5212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-475-6097
Provider Business Practice Location Address Fax Number:
865-475-5236
Provider Enumeration Date:
07/06/2006