Provider First Line Business Practice Location Address:
1108 POWELL LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLATWOODS
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41139-1614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-836-8086
Provider Business Practice Location Address Fax Number:
606-836-3743
Provider Enumeration Date:
12/30/2005