Provider First Line Business Practice Location Address:
160 C WEST MAIN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MT CARMEL
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-357-6231
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/31/2007