Provider First Line Business Practice Location Address: 
512 E STEPHENS ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MIDWAY
    Provider Business Practice Location Address State Name: 
KY
    Provider Business Practice Location Address Postal Code: 
40347-1112
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
859-846-5806
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/12/2018