Provider First Line Business Practice Location Address:
210B BIRCH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PADUCAH
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42001-4904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-564-3646
Provider Business Practice Location Address Fax Number:
270-443-3778
Provider Enumeration Date:
11/21/2016