Provider First Line Business Practice Location Address:
1 SPARKS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JAMESTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42629-2418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-343-2101
Provider Business Practice Location Address Fax Number:
270-343-2080
Provider Enumeration Date:
08/02/2005