Provider First Line Business Practice Location Address:
209 E MOUND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARLAN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40831-2321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-573-1975
Provider Business Practice Location Address Fax Number:
606-837-9389
Provider Enumeration Date:
06/27/2013