Provider First Line Business Practice Location Address:
602 ELM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRAB ORCHARD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40419-9793
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-355-7412
Provider Business Practice Location Address Fax Number:
606-355-7998
Provider Enumeration Date:
07/14/2005