Provider First Line Business Practice Location Address:
408 EAST MAPLE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANEYVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-879-6355
Provider Business Practice Location Address Fax Number:
270-879-6143
Provider Enumeration Date:
12/23/2005