Provider First Line Business Practice Location Address: 
501 DARBY CREEK
    Provider Second Line Business Practice Location Address: 
#11
    Provider Business Practice Location Address City Name: 
LEXINGTON
    Provider Business Practice Location Address State Name: 
KY
    Provider Business Practice Location Address Postal Code: 
40509
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
859-338-0466
    Provider Business Practice Location Address Fax Number: 
859-294-0802
    Provider Enumeration Date: 
10/04/2006