Provider First Line Business Practice Location Address:
1903 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PADUCAH
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42001-7105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-444-8183
Provider Business Practice Location Address Fax Number:
270-444-8147
Provider Enumeration Date:
02/03/2012