Provider First Line Business Practice Location Address:
108 NEW GLENDALE ROAD
Provider Second Line Business Practice Location Address:
PO BOX 2609
Provider Business Practice Location Address City Name:
ELIZABETHTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42702-2609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-737-5921
Provider Business Practice Location Address Fax Number:
270-982-0829
Provider Enumeration Date:
07/21/2017