Provider First Line Business Practice Location Address:
419 LICKING PIKE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILDER
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41071-3046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-360-0664
Provider Business Practice Location Address Fax Number:
859-360-3143
Provider Enumeration Date:
06/14/2011