Provider First Line Business Practice Location Address:
2489 HWY 644
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
LOUISA
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-638-1311
Provider Business Practice Location Address Fax Number:
606-638-3739
Provider Enumeration Date:
06/27/2006