Provider First Line Business Practice Location Address:
79 SOUTH SIDE MALL RD
Provider Second Line Business Practice Location Address:
401 SOUTH SIDE PROF. BLDG
Provider Business Practice Location Address City Name:
SOUTH WILLIAMSON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41503-3975
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-237-0073
Provider Business Practice Location Address Fax Number:
606-237-9967
Provider Enumeration Date:
08/24/2006