Provider First Line Business Practice Location Address:
950 N MULBERRY ST
Provider Second Line Business Practice Location Address:
SUITE 170
Provider Business Practice Location Address City Name:
ELIZABETHTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42701-3612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-360-1084
Provider Business Practice Location Address Fax Number:
270-360-8914
Provider Enumeration Date:
12/22/2006