Provider First Line Business Practice Location Address:
750 S PROVIDENT WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELIZABETHTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42701-5956
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-769-2393
Provider Business Practice Location Address Fax Number:
270-769-2993
Provider Enumeration Date:
01/25/2007