Provider First Line Business Practice Location Address:
1467 N MACK SMITH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST RIDGE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37412-3947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-894-4403
Provider Business Practice Location Address Fax Number:
423-894-4513
Provider Enumeration Date:
05/26/2006