Provider First Line Business Practice Location Address:
120 S MANTLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELIZABETHTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42701-1606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-417-9675
Provider Business Practice Location Address Fax Number:
270-360-0840
Provider Enumeration Date:
07/23/2026