Provider First Line Business Practice Location Address:
1184 S LAKE DR STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESTONSBURG
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41653-1349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-506-4340
Provider Business Practice Location Address Fax Number:
606-506-4339
Provider Enumeration Date:
04/23/2012