Provider First Line Business Practice Location Address:
100 LR JOHNSON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PIKEVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-432-6004
Provider Business Practice Location Address Fax Number:
606-432-6644
Provider Enumeration Date:
09/14/2006