Provider First Line Business Practice Location Address:
2410 SUSANNAH ST
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:
37601-1765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-282-9011
Provider Business Practice Location Address Fax Number:
423-722-0288
Provider Enumeration Date:
12/08/2006