Provider First Line Business Practice Location Address:
1114 FASHION RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DRY RIDGE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41035-9609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-824-4415
Provider Business Practice Location Address Fax Number:
859-824-4497
Provider Enumeration Date:
01/19/2007