Provider First Line Business Practice Location Address:
3165 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:
41224-9113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-534-4002
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/28/2024