Provider First Line Business Practice Location Address:
304 W. STATE LINE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FULTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42041-1547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-472-1553
Provider Business Practice Location Address Fax Number:
270-472-6921
Provider Enumeration Date:
01/24/2007