Provider First Line Business Practice Location Address:
919 E CENTRAL AVENUE
Provider Second Line Business Practice Location Address:
SUITE 201
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:
423-563-5499
Provider Business Practice Location Address Fax Number:
423-563-5497
Provider Enumeration Date:
04/24/2006