Provider First Line Business Practice Location Address:
1000 NEIGHBORHOOD PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRDALE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40118-9697
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-361-2381
Provider Business Practice Location Address Fax Number:
502-996-8309
Provider Enumeration Date:
08/20/2024