Provider First Line Business Practice Location Address:
222 MAIN ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIVERMORE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42352-0490
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-278-2385
Provider Business Practice Location Address Fax Number:
270-278-5111
Provider Enumeration Date:
10/26/2006