Provider First Line Business Practice Location Address:
414 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST LIBERTY
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41472-1014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-743-3163
Provider Business Practice Location Address Fax Number:
606-743-3335
Provider Enumeration Date:
11/25/2006