Provider First Line Business Practice Location Address:
905 E CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFOLLETTE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37766-2055
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-907-1600
Provider Business Practice Location Address Fax Number:
423-907-1646
Provider Enumeration Date:
11/17/2005