Provider First Line Business Practice Location Address:
409 N STEWARTS LANE
Provider Second Line Business Practice Location Address:
WILDERNESS TRACE CHILD DEV CENTER
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40422-1423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-236-0878
Provider Business Practice Location Address Fax Number:
859-236-0878
Provider Enumeration Date:
04/27/2007