Provider First Line Business Practice Location Address:
1002 S BROADWAY ST STE 7
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:
40324-1463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-370-4336
Provider Business Practice Location Address Fax Number:
502-370-4352
Provider Enumeration Date:
05/09/2013