Provider First Line Business Practice Location Address:
10515 MEETING ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
PROSPECT
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40059-6523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-420-2480
Provider Business Practice Location Address Fax Number:
502-420-2891
Provider Enumeration Date:
03/24/2008