Provider First Line Business Practice Location Address:
1158 LEXINGTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40324-9330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-868-0338
Provider Business Practice Location Address Fax Number:
502-868-0438
Provider Enumeration Date:
09/15/2005