Provider First Line Business Practice Location Address:
1698 OLD LEBANON RD
Provider Second Line Business Practice Location Address:
SUITE 2A
Provider Business Practice Location Address City Name:
CAMPBELLSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42718-9662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-465-3561
Provider Business Practice Location Address Fax Number:
270-789-6119
Provider Enumeration Date:
07/28/2006