Provider First Line Business Practice Location Address:
247 MOHAWK STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROWNSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42210-0479
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-597-9024
Provider Business Practice Location Address Fax Number:
270-597-9024
Provider Enumeration Date:
10/02/2006