Provider First Line Business Practice Location Address:
638 E COLLEGE AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
STANTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40380-2363
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-318-3500
Provider Business Practice Location Address Fax Number:
606-318-3503
Provider Enumeration Date:
07/26/2006