Provider First Line Business Practice Location Address:
342 BOGLE ST
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42503-2851
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-679-7979
Provider Business Practice Location Address Fax Number:
606-678-0370
Provider Enumeration Date:
10/05/2005