Provider First Line Business Practice Location Address:
204 W PAIGE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOMPKINSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-487-5196
Provider Business Practice Location Address Fax Number:
270-487-5196
Provider Enumeration Date:
04/11/2007