Provider First Line Business Practice Location Address:
403 W FAIRVIEW AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDDYVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42038-8259
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-388-5454
Provider Business Practice Location Address Fax Number:
270-388-5452
Provider Enumeration Date:
12/28/2006