Provider First Line Business Practice Location Address:
912 WALLACE AVE
Provider Second Line Business Practice Location Address:
#105
Provider Business Practice Location Address City Name:
LEITCHFIELD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42754-2404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-528-4114
Provider Business Practice Location Address Fax Number:
270-230-0712
Provider Enumeration Date:
07/25/2006