Provider First Line Business Practice Location Address:
110 E MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40324-1780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-813-2744
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/12/2016