Provider First Line Business Practice Location Address:
106 SOUTHPORT DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-677-0053
Provider Business Practice Location Address Fax Number:
606-677-0060
Provider Enumeration Date:
06/26/2006