Provider First Line Business Practice Location Address:
900 FAIRDALE 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:
40118-9731
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-366-8778
Provider Business Practice Location Address Fax Number:
502-366-9163
Provider Enumeration Date:
05/19/2006