Provider First Line Business Practice Location Address:
508 FAIRDALE ROAD
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-361-1872
Provider Business Practice Location Address Fax Number:
502-363-0539
Provider Enumeration Date:
05/02/2007