Provider First Line Business Practice Location Address:
590 OLD 25 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARBOURVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40906-7490
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-546-8860
Provider Business Practice Location Address Fax Number:
606-545-6372
Provider Enumeration Date:
06/19/2006