Provider First Line Business Practice Location Address:
120 TRADEPARK DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42503-3454
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-679-9292
Provider Business Practice Location Address Fax Number:
606-679-9294
Provider Enumeration Date:
10/27/2006