Provider First Line Business Practice Location Address:
125 AUGUSTA AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
PADUCAH
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42003-5584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-534-0046
Provider Business Practice Location Address Fax Number:
270-534-0048
Provider Enumeration Date:
10/11/2006