Provider First Line Business Practice Location Address:
501 COLLEGE STREET
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-679-9289
Provider Business Practice Location Address Fax Number:
606-679-9289
Provider Enumeration Date:
08/29/2006