Provider First Line Business Practice Location Address:
600 1 2 CLIFTY STREET
Provider Second Line Business Practice Location Address:
SUITE 2 AND 3
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42503-1733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-679-9245
Provider Business Practice Location Address Fax Number:
606-678-9273
Provider Enumeration Date:
07/10/2006