Provider First Line Business Practice Location Address:
908 WALLACE AVE
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
LEITCHFIELD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42754-1479
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-259-8400
Provider Business Practice Location Address Fax Number:
844-607-4498
Provider Enumeration Date:
12/26/2005