Provider First Line Business Practice Location Address:
3623 E LOCUST CIR
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:
40059-9020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-228-6550
Provider Business Practice Location Address Fax Number:
502-228-6550
Provider Enumeration Date:
12/26/2007