Provider First Line Business Practice Location Address:
210 BLACK GOLD BLVD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
HAZARD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41701-2620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-487-7380
Provider Business Practice Location Address Fax Number:
606-487-7384
Provider Enumeration Date:
08/17/2016