Provider First Line Business Practice Location Address:
102 E MAIN ST STE 4
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:
40324-1788
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-517-9902
Provider Business Practice Location Address Fax Number:
859-399-6824
Provider Enumeration Date:
11/13/2020