Provider First Line Business Practice Location Address:
1005 WEST COLUMBIA ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-451-0668
Provider Business Practice Location Address Fax Number:
606-451-0078
Provider Enumeration Date:
12/30/2010