Provider First Line Business Practice Location Address:
211 WEST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT WASHINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40047-7636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-664-7533
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/25/2018