Provider First Line Business Practice Location Address:
25 MEDPARK SQUARE DR STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42503-1708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-676-0199
Provider Business Practice Location Address Fax Number:
606-457-7727
Provider Enumeration Date:
09/30/2011