Provider First Line Business Practice Location Address:
110 JOHNSON LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARBOURVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40906-1321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-546-5109
Provider Business Practice Location Address Fax Number:
606-546-4199
Provider Enumeration Date:
04/07/2008