Provider First Line Business Practice Location Address:
308 WEST MAPLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-792-6844
Provider Business Practice Location Address Fax Number:
859-792-1806
Provider Enumeration Date:
12/01/2005