Provider First Line Business Practice Location Address:
11708 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLETOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40243-1426
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-245-8627
Provider Business Practice Location Address Fax Number:
502-245-9395
Provider Enumeration Date:
08/31/2006