Provider First Line Business Practice Location Address:
515 N 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLESBORO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40965-1131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-248-2093
Provider Business Practice Location Address Fax Number:
606-248-0539
Provider Enumeration Date:
07/10/2006