Provider First Line Business Practice Location Address:
342 BOGLE ST
Provider Second Line Business Practice Location Address:
STE 1
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42503-2851
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-451-0216
Provider Business Practice Location Address Fax Number:
606-451-1959
Provider Enumeration Date:
07/07/2005