Provider First Line Business Practice Location Address:
1213 NORTH MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAVER DAM
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-274-4771
Provider Business Practice Location Address Fax Number:
270-274-4884
Provider Enumeration Date:
06/07/2006