Provider First Line Business Practice Location Address:
105 US HIGHWAY 41A N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROVIDENCE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42450-2126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-667-7031
Provider Business Practice Location Address Fax Number:
270-667-9254
Provider Enumeration Date:
02/01/2021