Provider First Line Business Practice Location Address:
257 RUSSELL STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELKHORN CITY
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-754-4949
Provider Business Practice Location Address Fax Number:
606-754-0333
Provider Enumeration Date:
02/21/2007