Provider First Line Business Practice Location Address:
401 S MAIN ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SMITHS GROVE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42171-8136
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-793-9611
Provider Business Practice Location Address Fax Number:
270-793-9503
Provider Enumeration Date:
09/16/2006