Provider First Line Business Practice Location Address:
104 LAWSON DR
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40324-8998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-867-0089
Provider Business Practice Location Address Fax Number:
502-867-0180
Provider Enumeration Date:
12/05/2007