Provider First Line Business Practice Location Address:
9409 BROWN AUSTIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRDALE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40118-9532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-565-0550
Provider Business Practice Location Address Fax Number:
502-565-0540
Provider Enumeration Date:
02/19/2015