Provider First Line Business Practice Location Address: 
625 CHESTNUT DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WALTON
    Provider Business Practice Location Address State Name: 
KY
    Provider Business Practice Location Address Postal Code: 
41094-7845
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
859-250-0507
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/18/2006