Provider First Line Business Practice Location Address:
105 MOHAWK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROWNSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42210-8544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-597-2333
Provider Business Practice Location Address Fax Number:
270-597-2333
Provider Enumeration Date:
09/29/2010