Provider First Line Business Practice Location Address: 
1225 CRANE POND RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PHILPOT
    Provider Business Practice Location Address State Name: 
KY
    Provider Business Practice Location Address Postal Code: 
42366-9206
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
270-993-3002
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/26/2013