Provider First Line Business Practice Location Address:
234 BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LACENTER
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-665-5192
Provider Business Practice Location Address Fax Number:
270-665-9296
Provider Enumeration Date:
03/20/2007