Provider First Line Business Practice Location Address:
162 SHARP AND PERKINS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSBORO
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37757-2507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-562-8351
Provider Business Practice Location Address Fax Number:
423-562-1593
Provider Enumeration Date:
03/14/2012