Provider First Line Business Practice Location Address:
77 MILLARD ALLEN DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LACKEY
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41643-0190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-358-2381
Provider Business Practice Location Address Fax Number:
606-358-2404
Provider Enumeration Date:
07/18/2005