Provider First Line Business Practice Location Address: 
209 N MAYSVILLE ST STE 200
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MOUNT STERLING
    Provider Business Practice Location Address State Name: 
KY
    Provider Business Practice Location Address Postal Code: 
40353-1179
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
859-404-7686
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/10/2015