Provider First Line Business Practice Location Address:
112 VINSON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISA
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41230-1155
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-638-4731
Provider Business Practice Location Address Fax Number:
606-638-3523
Provider Enumeration Date:
10/10/2005