Provider First Line Business Practice Location Address:
2208 ANTIOCH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBYVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40065-9754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-718-2272
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/13/2013