Provider First Line Business Practice Location Address:
695 KENTUCKY HIGHWAY 15 NORTH
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41339-0803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-666-9293
Provider Business Practice Location Address Fax Number:
606-666-9220
Provider Enumeration Date:
12/14/2006