Provider First Line Business Practice Location Address:
203 N TYLER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORGANTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42261-8431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-526-5624
Provider Business Practice Location Address Fax Number:
270-526-5625
Provider Enumeration Date:
09/03/2009