Provider First Line Business Practice Location Address: 
1140 STOURBRIDGE ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
VERSAILLES
    Provider Business Practice Location Address State Name: 
KY
    Provider Business Practice Location Address Postal Code: 
40383-1880
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
859-492-5678
    Provider Business Practice Location Address Fax Number: 
859-879-8004
    Provider Enumeration Date: 
03/23/2016