Provider First Line Business Practice Location Address:
1836 BROADWAY 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:
42001-2708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-442-0256
Provider Business Practice Location Address Fax Number:
270-442-8730
Provider Enumeration Date:
07/17/2015