Provider First Line Business Practice Location Address:
617 23RD STREET
Provider Second Line Business Practice Location Address:
MEDICAL PLAZA A SUITE 8B
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41101-2845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-408-7246
Provider Business Practice Location Address Fax Number:
606-408-7230
Provider Enumeration Date:
08/31/2006