Provider First Line Business Practice Location Address:
107 ISLAND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARLAN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40831-1904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-573-7447
Provider Business Practice Location Address Fax Number:
606-573-7930
Provider Enumeration Date:
11/07/2006