Provider First Line Business Practice Location Address:
13206 W HIGHWAY 42
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
PROSPECT
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40059-8221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-228-9494
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/19/2007