Provider First Line Business Practice Location Address: 
301 MED TECH PKWY STE 180
    Provider Second Line Business Practice Location Address: 
    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: 
423-794-5540
    Provider Business Practice Location Address Fax Number: 
423-926-9187
    Provider Enumeration Date: 
10/17/2006