Provider First Line Business Practice Location Address:
705 N 12TH ST
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
MIDDLESBORO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40965-1835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-302-4002
Provider Business Practice Location Address Fax Number:
606-302-4005
Provider Enumeration Date:
04/30/2012