Provider First Line Business Practice Location Address:
1008 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:
42701-2037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-769-0865
Provider Business Practice Location Address Fax Number:
270-769-0409
Provider Enumeration Date:
09/22/2011