Provider First Line Business Practice Location Address:
713 BROADWAY ST
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
PAINTSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41240-1465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-789-6632
Provider Business Practice Location Address Fax Number:
606-886-9908
Provider Enumeration Date:
05/09/2007