Provider First Line Business Practice Location Address:
113 IRVING LN
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:
40324-2094
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-912-4488
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/04/2014