Provider First Line Business Practice Location Address:
252 WEST 5TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA CENTER
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-665-5875
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/15/2007