Provider First Line Business Practice Location Address:
412 N LOCK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISA
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41230-1115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-638-4595
Provider Business Practice Location Address Fax Number:
606-638-9471
Provider Enumeration Date:
09/24/2007