Provider First Line Business Practice Location Address:
128 KENTUCKY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRVINE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40336-1266
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-723-6629
Provider Business Practice Location Address Fax Number:
606-723-9726
Provider Enumeration Date:
07/12/2007