Provider First Line Business Practice Location Address:
110 BARRETT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROVIDENCE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-667-7073
Provider Business Practice Location Address Fax Number:
270-667-7073
Provider Enumeration Date:
02/21/2007