Provider First Line Business Practice Location Address:
716 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAINTSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41240-1357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-220-2553
Provider Business Practice Location Address Fax Number:
606-220-2554
Provider Enumeration Date:
04/14/2011