Provider First Line Business Practice Location Address:
30 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBYVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40065-1020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-845-2761
Provider Business Practice Location Address Fax Number:
502-845-7998
Provider Enumeration Date:
11/22/2005