Provider First Line Business Practice Location Address:
510 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POWDERLY
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42367-5487
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-338-2871
Provider Business Practice Location Address Fax Number:
270-338-0529
Provider Enumeration Date:
01/08/2007