Provider First Line Business Practice Location Address:
137 STATE ROUTE 3117
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH SHORE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41175
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-932-2079
Provider Business Practice Location Address Fax Number:
606-932-2313
Provider Enumeration Date:
11/21/2006