Provider First Line Business Practice Location Address:
413 S LOOP RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDGEWOOD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41017-5446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-301-3800
Provider Business Practice Location Address Fax Number:
859-301-3987
Provider Enumeration Date:
03/19/2007