Provider First Line Business Practice Location Address:
9219 US HIGHWAY 42 STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROSPECT
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40059-8875
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-228-2709
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/26/2022