Provider First Line Business Practice Location Address:
14 MOONBOW PLZ
Provider Second Line Business Practice Location Address:
STE 1
Provider Business Practice Location Address City Name:
CORBIN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40701-8910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-523-5585
Provider Business Practice Location Address Fax Number:
606-523-4418
Provider Enumeration Date:
12/26/2006