Provider First Line Business Practice Location Address:
1123 N BARDSTOWN RD
Provider Second Line Business Practice Location Address:
SUITE #2
Provider Business Practice Location Address City Name:
MT WASHINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40047-7843
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-472-1194
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/23/2007