Provider First Line Business Practice Location Address:
210 MEADOWS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MT WASHINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40047-6013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-361-2301
Provider Business Practice Location Address Fax Number:
502-363-6114
Provider Enumeration Date:
12/30/2005