Provider First Line Business Practice Location Address: 
26 WOODLAND HLS
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HARLAN
    Provider Business Practice Location Address State Name: 
KY
    Provider Business Practice Location Address Postal Code: 
40831-2562
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
160-657-3455
    Provider Business Practice Location Address Fax Number: 
606-573-4402
    Provider Enumeration Date: 
09/07/2022