Provider First Line Business Practice Location Address:
428 HUSTONVILLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIBERTY
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42539-3140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-787-2688
Provider Business Practice Location Address Fax Number:
606-787-2687
Provider Enumeration Date:
11/19/2011