Provider First Line Business Practice Location Address:
117 MAIN STREET
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:
41224-0306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-298-7512
Provider Business Practice Location Address Fax Number:
606-298-7615
Provider Enumeration Date:
11/01/2006