Provider First Line Business Practice Location Address: 
1019 MAJESTIC DR
    Provider Second Line Business Practice Location Address: 
SUITE 160
    Provider Business Practice Location Address City Name: 
LEXINGTON
    Provider Business Practice Location Address State Name: 
KY
    Provider Business Practice Location Address Postal Code: 
40513-1895
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
859-446-5603
    Provider Business Practice Location Address Fax Number: 
859-223-0494
    Provider Enumeration Date: 
04/07/2006