Provider First Line Business Practice Location Address:
473 N 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLESBORO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40965-1133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-302-5116
Provider Business Practice Location Address Fax Number:
606-302-5117
Provider Enumeration Date:
09/29/2011