Provider First Line Business Practice Location Address:
105 EASTSIDE DR
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:
40324-9797
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-866-0664
Provider Business Practice Location Address Fax Number:
502-866-0666
Provider Enumeration Date:
12/08/2011