Provider First Line Business Practice Location Address:
210 BLACK GOLD BLVD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
HAZARD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41701-2620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-439-1331
Provider Business Practice Location Address Fax Number:
606-439-6629
Provider Enumeration Date:
10/12/2007