Provider First Line Business Practice Location Address:
4690 W HIGHWAY 80
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:
42503-3763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-585-0258
Provider Business Practice Location Address Fax Number:
800-591-6398
Provider Enumeration Date:
02/20/2014