Provider First Line Business Practice Location Address:
110 ROACH ST
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:
40324-9393
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-863-4734
Provider Business Practice Location Address Fax Number:
502-863-4735
Provider Enumeration Date:
04/17/2014