Provider First Line Business Practice Location Address: 
800 ROSE ST PAV CC 2ND FLOOR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LEXINGTON
    Provider Business Practice Location Address State Name: 
KY
    Provider Business Practice Location Address Postal Code: 
40536-0001
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
859-257-4488
    Provider Business Practice Location Address Fax Number: 
859-323-1965
    Provider Enumeration Date: 
04/13/2015