Provider First Line Business Practice Location Address:
60 MARTHAS VINEYARD
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:
41653-1700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-874-9170
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/21/2007