Provider First Line Business Practice Location Address:
1255 N 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLESBORO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40965-1896
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-248-6288
Provider Business Practice Location Address Fax Number:
606-248-5489
Provider Enumeration Date:
07/26/2006