Provider First Line Business Practice Location Address:
908 WALLACE AVE STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEITCHFIELD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42754-1479
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-259-5224
Provider Business Practice Location Address Fax Number:
270-287-0173
Provider Enumeration Date:
10/23/2007