Provider First Line Business Practice Location Address:
DOGWOOD AVE, BLDG #1
Provider Second Line Business Practice Location Address:
ROOM 2-42
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-439-6263
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/19/2006