Provider First Line Business Practice Location Address:
402 BOGLE ST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42503-2870
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-451-3145
Provider Business Practice Location Address Fax Number:
606-451-3149
Provider Enumeration Date:
07/15/2011