Provider First Line Business Practice Location Address:
145 COUNTRY ESTATES RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAINT LICK
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40461-8500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-986-1438
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/01/2011