Provider First Line Business Practice Location Address:
104 S FRONT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESTONSBURG
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41653-1614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-886-8572
Provider Business Practice Location Address Fax Number:
606-886-4433
Provider Enumeration Date:
09/17/2006