Provider First Line Business Practice Location Address:
1416 S LAKE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESTONSBURG
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41653-1353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-886-7839
Provider Business Practice Location Address Fax Number:
606-886-9469
Provider Enumeration Date:
11/02/2006