Provider First Line Business Practice Location Address:
1005 W COLUMBIA ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42503-2720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-271-6693
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/25/2015