Provider First Line Business Practice Location Address:
1205 WOODLAND DR
Provider Second Line Business Practice Location Address:
SUITE B 100
Provider Business Practice Location Address City Name:
ELIZABETHTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42701-2709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-766-1055
Provider Business Practice Location Address Fax Number:
270-766-1056
Provider Enumeration Date:
12/17/2013