Provider First Line Business Practice Location Address:
204 N MAIN ST
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:
42701-1417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
279-769-2804
Provider Business Practice Location Address Fax Number:
270-360-0333
Provider Enumeration Date:
04/26/2007