Provider First Line Business Practice Location Address:
250 MEDLOCK RD
Provider Second Line Business Practice Location Address:
SIDE B
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40517-1148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-552-6454
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/24/2011