Provider First Line Business Practice Location Address:
2150 DIXIE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FT MITCHELL
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41017-2902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-292-1784
Provider Business Practice Location Address Fax Number:
859-292-1785
Provider Enumeration Date:
11/22/2010