Provider First Line Business Practice Location Address:
HWY 11 SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOONEVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-593-6323
Provider Business Practice Location Address Fax Number:
606-436-5797
Provider Enumeration Date:
09/07/2006