Provider First Line Business Practice Location Address:
1697 MONMOUTH ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
NEWPORT
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41071-2664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-292-0123
Provider Business Practice Location Address Fax Number:
859-292-0131
Provider Enumeration Date:
11/10/2008