Provider First Line Business Practice Location Address:
136 PROFESSIONAL AVE
Provider Second Line Business Practice Location Address:
SUITE 8
Provider Business Practice Location Address City Name:
WINCHESTER
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40391-1116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-744-9252
Provider Business Practice Location Address Fax Number:
859-744-9118
Provider Enumeration Date:
10/12/2006