Provider First Line Business Practice Location Address:
1401 NANCY PRIDDY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UPTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42784-9288
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-974-4605
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/22/2026