Provider First Line Business Practice Location Address:
511 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POWDERLY
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42367-5487
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-338-5050
Provider Business Practice Location Address Fax Number:
270-338-5075
Provider Enumeration Date:
05/26/2011