Provider First Line Business Practice Location Address:
104 MOHAWK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROWNSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42210-9006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-597-2155
Provider Business Practice Location Address Fax Number:
270-597-3811
Provider Enumeration Date:
10/26/2016