Provider First Line Business Practice Location Address:
120 PROFESSIONAL LANE
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
HARLAN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40831-2603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-573-1004
Provider Business Practice Location Address Fax Number:
606-573-0059
Provider Enumeration Date:
01/19/2006