Provider First Line Business Practice Location Address:
917 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAINTSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41240-1407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-788-0433
Provider Business Practice Location Address Fax Number:
606-789-5053
Provider Enumeration Date:
01/05/2007