Provider First Line Business Practice Location Address:
204 S. MAIN ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA FAYETTE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42254-0014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-271-8287
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/22/2007