Provider First Line Business Practice Location Address:
2109 W MARKET ST
Provider Second Line Business Practice Location Address:
ROOM 143
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-439-8830
Provider Business Practice Location Address Fax Number:
423-439-8580
Provider Enumeration Date:
08/25/2005