Provider First Line Business Practice Location Address:
1150 PAYNES DEPOT RD
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:
40324-9137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-940-0375
Provider Business Practice Location Address Fax Number:
502-305-2114
Provider Enumeration Date:
05/11/2023