Provider First Line Business Practice Location Address:
215 E MAIN 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:
42450-1261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-828-5784
Provider Business Practice Location Address Fax Number:
270-825-5204
Provider Enumeration Date:
01/15/2010