Provider First Line Business Practice Location Address:
713 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAINTSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41240-1465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-789-7040
Provider Business Practice Location Address Fax Number:
606-789-3035
Provider Enumeration Date:
04/10/2007