Provider First Line Business Practice Location Address:
832 HIGHWAY 15 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41339-8284
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-666-5142
Provider Business Practice Location Address Fax Number:
606-666-4172
Provider Enumeration Date:
08/01/2006