Provider First Line Business Practice Location Address:
604 OGDEN ST
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42501-5826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-295-9971
Provider Business Practice Location Address Fax Number:
859-685-7659
Provider Enumeration Date:
01/06/2010