Provider First Line Business Practice Location Address:
RT 40 EAST BLACKLOG RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INEZ
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-298-7405
Provider Business Practice Location Address Fax Number:
606-298-3284
Provider Enumeration Date:
09/27/2007