Provider First Line Business Practice Location Address:
240 W DIXIE,
Provider Second Line Business Practice Location Address:
SUITE 5-B
Provider Business Practice Location Address City Name:
ELIZABETHTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42701-1575
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-401-4107
Provider Business Practice Location Address Fax Number:
270-209-0872
Provider Enumeration Date:
05/25/2006