Provider First Line Business Practice Location Address:
1201 FREDERICA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OWENSBORO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42301-3058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-490-5202
Provider Business Practice Location Address Fax Number:
270-225-3028
Provider Enumeration Date:
10/22/2026