Provider First Line Business Practice Location Address:
544 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
SHELBYVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40065-1120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-682-7647
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/05/2012