Provider First Line Business Practice Location Address:
409 OGDEN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42501-1723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-679-1965
Provider Business Practice Location Address Fax Number:
606-678-8465
Provider Enumeration Date:
07/28/2006