Provider First Line Business Practice Location Address: 
64A ROGER COMBS BLVD.
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HINDMAN
    Provider Business Practice Location Address State Name: 
KY
    Provider Business Practice Location Address Postal Code: 
41822
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
606-785-0889
    Provider Business Practice Location Address Fax Number: 
606-785-5772
    Provider Enumeration Date: 
07/24/2006