Provider First Line Business Practice Location Address: 
336 29TH ST STE 101
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ASHLAND
    Provider Business Practice Location Address State Name: 
KY
    Provider Business Practice Location Address Postal Code: 
41101-1976
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
606-324-4404
    Provider Business Practice Location Address Fax Number: 
606-326-1159
    Provider Enumeration Date: 
11/04/2009