Provider First Line Business Practice Location Address:
117 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42078-9998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-988-3839
Provider Business Practice Location Address Fax Number:
270-988-3832
Provider Enumeration Date:
07/18/2019