Provider First Line Business Practice Location Address:
425 CLINIC DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOREHEAD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40351-1077
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-407-4412
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/11/2007