Provider First Line Business Practice Location Address:
819 NEW GLENDALE ROAD
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-624-9002
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/20/2006