Provider First Line Business Practice Location Address:
1285 DAIRY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRVINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40146-5387
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-526-8484
Provider Business Practice Location Address Fax Number:
615-610-0749
Provider Enumeration Date:
02/18/2026