Provider First Line Business Practice Location Address:
10701 W MANSLICK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRDALE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40118-9581
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-367-2112
Provider Business Practice Location Address Fax Number:
502-367-7799
Provider Enumeration Date:
12/29/2006