Provider First Line Business Practice Location Address:
2160 BLACKLOG RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INEZ
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41224-9019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-298-7283
Provider Business Practice Location Address Fax Number:
606-298-4538
Provider Enumeration Date:
02/09/2021