Provider First Line Business Practice Location Address:
768 OLD LICK CREEK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISA
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41230-5947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-972-3937
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/21/2026