Provider First Line Business Practice Location Address:
129 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42078-8065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-988-2675
Provider Business Practice Location Address Fax Number:
270-988-2929
Provider Enumeration Date:
10/23/2006