Provider First Line Business Practice Location Address:
134 N GARDNER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCOTTSBURG
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47170-1306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-226-3937
Provider Business Practice Location Address Fax Number:
502-226-2929
Provider Enumeration Date:
01/20/2012