Provider First Line Business Practice Location Address:
600 CLIFTY ST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42503-3124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-678-0026
Provider Business Practice Location Address Fax Number:
606-678-0047
Provider Enumeration Date:
06/12/2020