Provider First Line Business Practice Location Address:
2483 HIGHWAY 644
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
LOUISA
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41230-9242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-638-9954
Provider Business Practice Location Address Fax Number:
606-638-3595
Provider Enumeration Date:
10/18/2005