Provider First Line Business Practice Location Address:
ROUTE 3
Provider Second Line Business Practice Location Address:
BOX 31
Provider Business Practice Location Address City Name:
VANCEBURG
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41179-0550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-796-3029
Provider Business Practice Location Address Fax Number:
606-796-6221
Provider Enumeration Date:
08/23/2006