Provider First Line Business Practice Location Address:
604 OGDEN ST
Provider Second Line Business Practice Location Address:
STE 202
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42501-1795
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-679-1991
Provider Business Practice Location Address Fax Number:
606-679-1149
Provider Enumeration Date:
01/24/2011