Provider First Line Business Practice Location Address:
1115 KENTUCKY LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAINTSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41240-9368
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-398-8234
Provider Business Practice Location Address Fax Number:
866-259-4181
Provider Enumeration Date:
10/19/2015