Provider First Line Business Practice Location Address:
221 HIGHWAY 15 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41339-9600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-272-6854
Provider Business Practice Location Address Fax Number:
606-824-9078
Provider Enumeration Date:
07/28/2005