Provider First Line Business Practice Location Address:
105 MAGNOLIA DR STE 2
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:
40324-8046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-642-4048
Provider Business Practice Location Address Fax Number:
502-642-4410
Provider Enumeration Date:
03/18/2026