Provider First Line Business Practice Location Address:
1075 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISONVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42431-1288
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-476-0409
Provider Business Practice Location Address Fax Number:
812-476-1016
Provider Enumeration Date:
07/30/2007