Provider First Line Business Practice Location Address:
950 NORTH MULBERRY STREET
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
ELIZABETHTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-737-6804
Provider Business Practice Location Address Fax Number:
270-737-0533
Provider Enumeration Date:
04/25/2007