Provider First Line Business Practice Location Address:
401 BOGLE ST
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42503-2850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-677-2733
Provider Business Practice Location Address Fax Number:
606-679-7561
Provider Enumeration Date:
07/15/2005