Provider First Line Business Practice Location Address:
475 LANDIS LN LOT 136
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT WASHINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40047-7099
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-504-4002
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/21/2026