Provider First Line Business Practice Location Address:
2101 MINE FORK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALYERSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41465-9032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-349-2586
Provider Business Practice Location Address Fax Number:
606-349-4399
Provider Enumeration Date:
11/28/2007