Provider First Line Business Practice Location Address:
123 N 19TH ST STE C101
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:
40965-2865
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-896-8003
Provider Business Practice Location Address Fax Number:
606-896-8004
Provider Enumeration Date:
09/24/2012