Provider First Line Business Practice Location Address:
54 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRODHEAD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40409-8890
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-758-4373
Provider Business Practice Location Address Fax Number:
606-758-4764
Provider Enumeration Date:
12/27/2006