Provider First Line Business Practice Location Address:
223 S MAIN ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
VERSAILLES
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40383-1581
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-879-3377
Provider Business Practice Location Address Fax Number:
859-879-8377
Provider Enumeration Date:
05/27/2006