Provider First Line Business Practice Location Address:
638 E COLLEGE AVE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STANTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40380-2363
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-318-3500
Provider Business Practice Location Address Fax Number:
606-606-3503
Provider Enumeration Date:
08/30/2005