Provider First Line Business Practice Location Address:
187 WOLFORD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIBERTY
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42539-3187
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-787-6275
Provider Business Practice Location Address Fax Number:
606-787-8925
Provider Enumeration Date:
02/14/2006