Provider First Line Business Practice Location Address:
108 ELMORE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDMONTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-432-7211
Provider Business Practice Location Address Fax Number:
270-432-7215
Provider Enumeration Date:
11/09/2006