Provider First Line Business Practice Location Address: 
5308 GREENBRIAR RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CHATTANOOGA
    Provider Business Practice Location Address State Name: 
TN
    Provider Business Practice Location Address Postal Code: 
37412-3002
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
706-937-3331
    Provider Business Practice Location Address Fax Number: 
706-937-3346
    Provider Enumeration Date: 
12/02/2014