Provider First Line Business Practice Location Address:
116 WALLACE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROVIDENCE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42450-1278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-667-0940
Provider Business Practice Location Address Fax Number:
270-667-0941
Provider Enumeration Date:
12/30/2011