Provider First Line Business Practice Location Address:
8274 SCHOOL RD UNIT A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT CAMPBELL
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42223-2619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-479-2835
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/29/2025