Provider First Line Business Practice Location Address:
176 SOUTHPORT DRIVE
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:
42501-4149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-679-7562
Provider Business Practice Location Address Fax Number:
606-677-2557
Provider Enumeration Date:
12/28/2006