Provider First Line Business Practice Location Address: 
12902 WILLOWCREEK RD
    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: 
40059-9721
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
502-228-7993
    Provider Business Practice Location Address Fax Number: 
502-228-7993
    Provider Enumeration Date: 
05/15/2007