Provider First Line Business Practice Location Address:
150 MOUNT VERNON DR
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:
40324-1410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-218-1710
Provider Business Practice Location Address Fax Number:
502-218-1711
Provider Enumeration Date:
03/27/2020