Provider First Line Business Practice Location Address:
123 N 19TH ST
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
MIDDLESBORO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40965-2865
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-248-1062
Provider Business Practice Location Address Fax Number:
606-248-1224
Provider Enumeration Date:
05/12/2006