Provider First Line Business Practice Location Address:
3107 SALT LICK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRESTWOOD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40014-0909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-649-5415
Provider Business Practice Location Address Fax Number:
502-588-0326
Provider Enumeration Date:
01/31/2011