Provider First Line Business Practice Location Address:
6301 BASS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROSPECT
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40059-9384
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-273-9800
Provider Business Practice Location Address Fax Number:
216-273-9998
Provider Enumeration Date:
12/12/2025