Provider First Line Business Practice Location Address: 
211 FOUNTAIN CT
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LEXINGTON
    Provider Business Practice Location Address State Name: 
KY
    Provider Business Practice Location Address Postal Code: 
40509-2694
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
859-264-9820
    Provider Business Practice Location Address Fax Number: 
859-543-0994
    Provider Enumeration Date: 
09/01/2005