Provider First Line Business Practice Location Address:
202 BACK STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRENCHBURG
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40322-0110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-768-8002
Provider Business Practice Location Address Fax Number:
606-768-8050
Provider Enumeration Date:
01/02/2007