Provider First Line Business Practice Location Address:
964 BROADWAY ST
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
PAINTSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41240-1346
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-789-6996
Provider Business Practice Location Address Fax Number:
606-789-6997
Provider Enumeration Date:
06/29/2006