Provider First Line Business Practice Location Address:
223 GREGORY LANE
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-546-9722
Provider Business Practice Location Address Fax Number:
606-546-2106
Provider Enumeration Date:
07/21/2005