Provider First Line Business Practice Location Address:
297 TERRELL LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARBOURVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40906-7862
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-546-9241
Provider Business Practice Location Address Fax Number:
606-546-6992
Provider Enumeration Date:
09/20/2005