Provider First Line Business Practice Location Address: 
395 ELAINE DR STE 120
    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: 
40504-2705
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
859-255-3301
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/20/2006