Provider First Line Business Practice Location Address:
132 S LAKE DR STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESTONSBURG
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41653-1903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-866-0854
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/20/2006