Provider First Line Business Practice Location Address: 
1413 ABBOTT CREEK RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PRESTONSBURG
    Provider Business Practice Location Address State Name: 
KY
    Provider Business Practice Location Address Postal Code: 
41653-8930
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
606-791-4460
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/06/2014