Provider First Line Business Practice Location Address:
13011 W HIGHWAY 42 STE 208A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROSPECT
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40059-7165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-795-5034
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/04/2026