Provider First Line Business Practice Location Address: 
210 BLACK GOLD BLVD STE 105
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HAZARD
    Provider Business Practice Location Address State Name: 
KY
    Provider Business Practice Location Address Postal Code: 
41701-2620
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
606-439-6757
    Provider Business Practice Location Address Fax Number: 
606-487-7438
    Provider Enumeration Date: 
09/07/2005