Provider First Line Business Practice Location Address:
1049 JEFFERSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PADUCAH
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42001-1833
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-575-4529
Provider Business Practice Location Address Fax Number:
270-575-1075
Provider Enumeration Date:
05/15/2013