Provider First Line Business Practice Location Address:
313 WEST ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
PAINTSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41240-1054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-789-5979
Provider Business Practice Location Address Fax Number:
606-788-0387
Provider Enumeration Date:
04/24/2012