Provider First Line Business Practice Location Address:
285 PLUM FRK
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:
41175-8881
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-821-2402
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/11/2025