Provider First Line Business Practice Location Address:
1512 FREDERICA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OWENSBORO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42301-4805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-683-9992
Provider Business Practice Location Address Fax Number:
270-683-9993
Provider Enumeration Date:
08/24/2022