Provider First Line Business Practice Location Address:
79 AVIS LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH PORTSMOUTH
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41174-9081
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-932-6901
Provider Business Practice Location Address Fax Number:
740-533-2273
Provider Enumeration Date:
11/02/2007