Provider First Line Business Practice Location Address:
142 DEPOT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH SHORE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41175-9306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-932-2138
Provider Business Practice Location Address Fax Number:
606-932-2120
Provider Enumeration Date:
02/03/2021