Provider First Line Business Practice Location Address:
212 LAKE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FULTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42041-1544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-472-2421
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/09/2006