Provider First Line Business Practice Location Address:
1661 HIGHWAY 192 W STE 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONDON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40741-2305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-999-1249
Provider Business Practice Location Address Fax Number:
502-371-6665
Provider Enumeration Date:
01/13/2026