Provider First Line Business Practice Location Address:
2415 W HIGHWAY 72
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
HARLAN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40831-7077
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-273-5359
Provider Business Practice Location Address Fax Number:
606-573-8321
Provider Enumeration Date:
11/06/2013