Provider First Line Business Practice Location Address:
1101 EAST MASTER STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORBIN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40701-3511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-528-2881
Provider Business Practice Location Address Fax Number:
696-528-0293
Provider Enumeration Date:
12/16/2005