Provider First Line Business Practice Location Address:
12921 W HIGHWAY 42 STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROSPECT
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40059-7168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-435-4827
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/07/2007