Provider First Line Business Practice Location Address:
208 LAKE ST
Provider Second Line Business Practice Location Address:
C/ O EVANS TOTAL CARE, LLC
Provider Business Practice Location Address City Name:
FULTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42041-1544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-472-2984
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/24/2006