Provider First Line Business Practice Location Address:
40 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DRY RIDGE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41035-9762
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
185-982-3020
Provider Business Practice Location Address Fax Number:
185-982-3450
Provider Enumeration Date:
09/30/2008