Provider First Line Business Practice Location Address:
115 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRVINE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40336-1084
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-723-3555
Provider Business Practice Location Address Fax Number:
606-723-5816
Provider Enumeration Date:
04/19/2007