Provider First Line Business Practice Location Address:
726 HIGHWAY 15 N
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41339-8601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-693-0116
Provider Business Practice Location Address Fax Number:
606-693-0118
Provider Enumeration Date:
07/19/2005