Provider First Line Business Practice Location Address:
161 WEST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MT WASHINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40047-7636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-538-7425
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/07/2010