Provider First Line Business Practice Location Address: 
1269 DUVALL RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BEAVER DAM
    Provider Business Practice Location Address State Name: 
KY
    Provider Business Practice Location Address Postal Code: 
42320-8637
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
270-274-0650
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/04/2015