Provider First Line Business Practice Location Address:
201 CASTLE 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:
40324-9473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-750-0224
Provider Business Practice Location Address Fax Number:
646-750-0224
Provider Enumeration Date:
10/01/2026