Provider First Line Business Practice Location Address:
737 N HIGHWAY 31E BYP STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MT WASHINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40047-7548
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-909-0772
Provider Business Practice Location Address Fax Number:
855-859-0123
Provider Enumeration Date:
05/04/2026