Provider First Line Business Practice Location Address:
9523 US HIGHWAY 42
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROSPECT
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40059-5054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-465-3674
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/25/2025