Provider First Line Business Practice Location Address:
3701 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:
42301-6975
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-683-9551
Provider Business Practice Location Address Fax Number:
270-685-2225
Provider Enumeration Date:
10/19/2006