Provider First Line Business Practice Location Address:
972 BROADWAY PLAZA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAINTSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-789-1912
Provider Business Practice Location Address Fax Number:
606-789-1939
Provider Enumeration Date:
02/23/2007