Provider First Line Business Practice Location Address: 
1320 OAK RIDGE CT
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SIMPSONVILLE
    Provider Business Practice Location Address State Name: 
KY
    Provider Business Practice Location Address Postal Code: 
40067-6668
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
502-722-0492
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/14/2006