Provider First Line Business Practice Location Address:
1724 5TH STREET RD APT 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORBIN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40701-9665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-524-2144
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/25/2025