Provider First Line Business Practice Location Address:
11510 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLETOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-553-0652
Provider Business Practice Location Address Fax Number:
502-409-5775
Provider Enumeration Date:
06/24/2010