Provider First Line Business Practice Location Address: 
250 LONE OAK RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PADUCAH
    Provider Business Practice Location Address State Name: 
KY
    Provider Business Practice Location Address Postal Code: 
42001-4400
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
270-443-1442
    Provider Business Practice Location Address Fax Number: 
270-444-0610
    Provider Enumeration Date: 
01/31/2006