Provider First Line Business Practice Location Address:
196 LOGSTON LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEREA
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40403-2114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-986-1207
Provider Business Practice Location Address Fax Number:
859-985-5463
Provider Enumeration Date:
04/27/2010