Provider First Line Business Practice Location Address:
907 N. MULBERRY ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELIZABETHTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42701-2033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-505-1087
Provider Business Practice Location Address Fax Number:
270-505-1239
Provider Enumeration Date:
05/21/2007