Provider First Line Business Practice Location Address:
210 JACKS SHOPPING CTR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCOTTSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42164-1619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-239-6700
Provider Business Practice Location Address Fax Number:
270-239-6701
Provider Enumeration Date:
08/31/2005