Provider First Line Business Practice Location Address:
3073 DIXIE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDGEWOOD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41018-1829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-344-0434
Provider Business Practice Location Address Fax Number:
859-344-1658
Provider Enumeration Date:
07/10/2006