Provider First Line Business Practice Location Address:
6436 STATE ROUTE 784
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH SHORE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41175-8621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-923-0122
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/21/2006