Provider First Line Business Practice Location Address:
10617 JEFFERSON HILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRDALE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40118-9042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-367-2368
Provider Business Practice Location Address Fax Number:
502-367-2368
Provider Enumeration Date:
10/13/2011