Provider First Line Business Practice Location Address: 
2202 MARTIN LUTHER KING JR BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PARIS
    Provider Business Practice Location Address State Name: 
KY
    Provider Business Practice Location Address Postal Code: 
40361-1281
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
833-510-4357
    Provider Business Practice Location Address Fax Number: 
866-460-2997
    Provider Enumeration Date: 
04/15/2020