Provider First Line Business Practice Location Address:
114 N 5TH ST
Provider Second Line Business Practice Location Address:
SUITE 11
Provider Business Practice Location Address City Name:
BARDSTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40004-1449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-507-9765
Provider Business Practice Location Address Fax Number:
502-348-0121
Provider Enumeration Date:
05/23/2006