Provider First Line Business Practice Location Address:
1018 IVAL JAMES BLVD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40475
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-626-9851
Provider Business Practice Location Address Fax Number:
859-626-9854
Provider Enumeration Date:
11/30/2007