Provider First Line Business Practice Location Address:
302 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROVIDENCE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42450-1140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-667-7007
Provider Business Practice Location Address Fax Number:
270-667-7606
Provider Enumeration Date:
06/12/2007