Provider First Line Business Practice Location Address:
496 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH SHORE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41175-7525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-498-4042
Provider Business Practice Location Address Fax Number:
606-498-4057
Provider Enumeration Date:
03/18/2024