Provider First Line Business Practice Location Address:
1200 N BARDSTOWN RD
Provider Second Line Business Practice Location Address:
STE. B
Provider Business Practice Location Address City Name:
MT WASHINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40047-7669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-904-9662
Provider Business Practice Location Address Fax Number:
502-904-9663
Provider Enumeration Date:
06/21/2010