Provider First Line Business Practice Location Address:
1803 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CUMBERLAND
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40823-1840
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-589-0003
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/01/2008