Provider First Line Business Practice Location Address:
BUILDING 7149 BLACKSHEEP RUN RD
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:
42223-5318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-412-8688
Provider Business Practice Location Address Fax Number:
270-412-8421
Provider Enumeration Date:
03/23/2010