Provider First Line Business Practice Location Address:
912 WALLACE AVE
Provider Second Line Business Practice Location Address:
STE 106
Provider Business Practice Location Address City Name:
LEITCHFIELD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42754-2405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-230-0163
Provider Business Practice Location Address Fax Number:
270-230-0173
Provider Enumeration Date:
04/20/2006