Provider First Line Business Practice Location Address: 
2250 LEESTOWN RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LEXINGTON
    Provider Business Practice Location Address State Name: 
KY
    Provider Business Practice Location Address Postal Code: 
40511-1052
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
859-233-4511
    Provider Business Practice Location Address Fax Number: 
859-281-3867
    Provider Enumeration Date: 
03/09/2007