Provider First Line Business Practice Location Address:
112 E. MAIN ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELKHORN CITY
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-754-0221
Provider Business Practice Location Address Fax Number:
606-754-0225
Provider Enumeration Date:
10/19/2006