Provider First Line Business Practice Location Address:
115 E STOCKTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDMONTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42129-9432
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-432-3051
Provider Business Practice Location Address Fax Number:
270-432-2682
Provider Enumeration Date:
07/29/2005