Provider First Line Business Practice Location Address:
206 LOCUST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROVIDENCE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42450-1514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-919-0863
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/15/2013