Provider First Line Business Practice Location Address:
402 BOGLE ST
Provider Second Line Business Practice Location Address:
SUITE #1
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42503-2870
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-679-8696
Provider Business Practice Location Address Fax Number:
606-678-2517
Provider Enumeration Date:
08/24/2005