Provider First Line Business Practice Location Address: 
49 STERLING AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FORT THOMAS
    Provider Business Practice Location Address State Name: 
KY
    Provider Business Practice Location Address Postal Code: 
41075-1148
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
859-442-9899
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/30/2007