Provider First Line Business Practice Location Address:
1805 S MAIN ST STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORBIN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40701-2405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-258-1995
Provider Business Practice Location Address Fax Number:
606-258-1996
Provider Enumeration Date:
12/13/2012