Provider First Line Business Practice Location Address:
218 W JOHN FITCH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARDSTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40004-1115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-348-9775
Provider Business Practice Location Address Fax Number:
502-348-2756
Provider Enumeration Date:
11/02/2005