Provider First Line Business Practice Location Address:
516 N 15TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLESBORO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40965-1126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-242-2377
Provider Business Practice Location Address Fax Number:
866-777-9165
Provider Enumeration Date:
09/15/2006