Provider First Line Business Practice Location Address:
10355 HIGHWAY 30 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOONEVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41314-9509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-464-0151
Provider Business Practice Location Address Fax Number:
606-464-0152
Provider Enumeration Date:
09/26/2023