Provider First Line Business Practice Location Address:
551 WESTPORT RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
ELIZABETHTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42701-2920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-982-7377
Provider Business Practice Location Address Fax Number:
270-982-4415
Provider Enumeration Date:
02/15/2007