Provider First Line Business Practice Location Address:
200 LARALAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRANKFORT
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40601-3630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-564-4269
Provider Business Practice Location Address Fax Number:
502-564-9640
Provider Enumeration Date:
11/16/2009