Provider First Line Business Practice Location Address:
216 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41002-1037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-756-2204
Provider Business Practice Location Address Fax Number:
606-756-2702
Provider Enumeration Date:
07/30/2006