Provider First Line Business Practice Location Address:
421 OGDEN ST STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42501-1768
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-341-4841
Provider Business Practice Location Address Fax Number:
606-772-0855
Provider Enumeration Date:
08/17/2010