Provider First Line Business Practice Location Address:
308 N DEPOT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40033-1422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-692-2652
Provider Business Practice Location Address Fax Number:
270-692-6099
Provider Enumeration Date:
12/15/2006