Provider First Line Business Practice Location Address:
924 N MULBERRY 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:
42701-3648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-360-9955
Provider Business Practice Location Address Fax Number:
270-360-9966
Provider Enumeration Date:
08/23/2005