Provider First Line Business Practice Location Address:
942 W MAIN ST UNIT B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40456-2523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-392-2207
Provider Business Practice Location Address Fax Number:
606-392-2139
Provider Enumeration Date:
06/17/2006