Provider First Line Business Practice Location Address:
613 23RD ST
Provider Second Line Business Practice Location Address:
MEDICAL PLAZA B SUITE G30
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41101-2878
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-329-1185
Provider Business Practice Location Address Fax Number:
606-324-0585
Provider Enumeration Date:
09/19/2006