Provider First Line Business Practice Location Address:
118 OLD LAFAYETTE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40502-1998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
598-687-7007
Provider Business Practice Location Address Fax Number:
859-687-7007
Provider Enumeration Date:
01/14/2015