Provider First Line Business Practice Location Address:
1293 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 142
Provider Business Practice Location Address City Name:
MONTICELLO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42633-1945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-348-8948
Provider Business Practice Location Address Fax Number:
606-340-0738
Provider Enumeration Date:
12/29/2006