Provider First Line Business Practice Location Address:
37 BALL PARK ROAD, SUITE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARLAN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40831-1793
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-574-8402
Provider Business Practice Location Address Fax Number:
606-574-8405
Provider Enumeration Date:
11/15/2012