Provider First Line Business Practice Location Address:
1009 LARK ST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37604-8217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-434-0110
Provider Business Practice Location Address Fax Number:
423-434-0095
Provider Enumeration Date:
08/21/2006