Provider First Line Business Practice Location Address:
RT 550, 77 MILLARD ALLEN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LACKEY
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-606-3582
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/22/2014