Provider First Line Business Practice Location Address:
587 N LAKE DR
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:
41653-1278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-886-7030
Provider Business Practice Location Address Fax Number:
606-886-9322
Provider Enumeration Date:
09/16/2005