Provider First Line Business Practice Location Address:
120 PROFESSIONAL LN STE 101
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:
40831-2601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-573-1085
Provider Business Practice Location Address Fax Number:
606-573-9956
Provider Enumeration Date:
02/21/2007