Provider First Line Business Practice Location Address:
112 E FRAZIER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42728-1920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-250-1606
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/16/2010