Provider First Line Business Practice Location Address:
1816 US RT 23 HALL BUILDING
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
SOUTH SHORE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41175-8103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-834-9648
Provider Business Practice Location Address Fax Number:
606-836-7561
Provider Enumeration Date:
09/14/2009