Provider First Line Business Practice Location Address:
2421 BROADWAY 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:
42001-7115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-450-6217
Provider Business Practice Location Address Fax Number:
270-450-6731
Provider Enumeration Date:
10/17/2006