Provider First Line Business Practice Location Address:
130 VINE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHEPHERDSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-543-7033
Provider Business Practice Location Address Fax Number:
502-955-9605
Provider Enumeration Date:
05/23/2007