Provider First Line Business Practice Location Address:
520 N MILES ST
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
ELIZABETHTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42701-1874
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-765-7408
Provider Business Practice Location Address Fax Number:
270-769-3910
Provider Enumeration Date:
06/16/2005