Provider First Line Business Practice Location Address:
81 SEVENTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH SHORE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41175-7871
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-887-0119
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/11/2013