Provider First Line Business Practice Location Address:
308 N MULBERRY ST
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:
42701-1846
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-765-5043
Provider Business Practice Location Address Fax Number:
270-769-5654
Provider Enumeration Date:
12/05/2005