Provider First Line Business Practice Location Address:
11569 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MATIN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42649-7813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-285-1112
Provider Business Practice Location Address Fax Number:
606-285-1114
Provider Enumeration Date:
10/20/2011