Provider First Line Business Practice Location Address:
311 NORTH 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLESBORO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-302-4011
Provider Business Practice Location Address Fax Number:
606-302-4085
Provider Enumeration Date:
01/25/2007