Provider First Line Business Practice Location Address:
111 N 21ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLESBORO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40965-1375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-248-2862
Provider Business Practice Location Address Fax Number:
606-248-2876
Provider Enumeration Date:
04/12/2012