Provider First Line Business Practice Location Address:
9160 CHILDRESS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST PADUCAH
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42086-9508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-443-3917
Provider Business Practice Location Address Fax Number:
270-415-9881
Provider Enumeration Date:
03/30/2007