Provider First Line Business Practice Location Address:
142 BLACK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARBOURVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40906-1483
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-219-4676
Provider Business Practice Location Address Fax Number:
606-896-2080
Provider Enumeration Date:
09/21/2022