Provider First Line Business Practice Location Address:
610 SOUTHERN CAMP DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUEYSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41640-0104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-358-9283
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/09/2007