Provider First Line Business Practice Location Address:
5663 HIGHWAY 90
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLAIRFIELD
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37715-3632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-784-6135
Provider Business Practice Location Address Fax Number:
423-784-8615
Provider Enumeration Date:
05/27/2005