Provider First Line Business Practice Location Address: 
104 CHESTNUT ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BARBOURVILLE
    Provider Business Practice Location Address State Name: 
KY
    Provider Business Practice Location Address Postal Code: 
40906-1643
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
606-627-1157
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/15/2020