Provider First Line Business Practice Location Address:
212 E CLOVER ST STE 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARLAN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40831-2394
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-273-1139
Provider Business Practice Location Address Fax Number:
800-331-2318
Provider Enumeration Date:
12/21/2023