Provider First Line Business Practice Location Address:
117 FERGUSON LN
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:
40324-1284
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-542-7133
Provider Business Practice Location Address Fax Number:
502-370-4521
Provider Enumeration Date:
03/27/2008