Provider First Line Business Practice Location Address:
200 E 4TH ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
TOMPKINSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42167-1611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-407-5454
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/08/2009