Provider First Line Business Practice Location Address:
610 LAUREL LAKE RESORT RD
Provider Second Line Business Practice Location Address:
STE 2
Provider Business Practice Location Address City Name:
CORBIN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40701-8844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-515-7137
Provider Business Practice Location Address Fax Number:
606-258-8211
Provider Enumeration Date:
06/17/2005