Provider First Line Business Practice Location Address:
2485 HIGHWAY 644
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
LOUISA
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41230-9242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-638-4656
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/02/2007