Provider First Line Business Practice Location Address:
110 HARDIN LANE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42503-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-451-9748
Provider Business Practice Location Address Fax Number:
606-451-0519
Provider Enumeration Date:
09/15/2006