Provider First Line Business Practice Location Address:
289 IRELAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT KNOX
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40121-5111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-526-1135
Provider Business Practice Location Address Fax Number:
812-526-1768
Provider Enumeration Date:
04/04/2007