Provider First Line Business Practice Location Address:
120 EDWARDS AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40324-9740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-863-1505
Provider Business Practice Location Address Fax Number:
502-863-1505
Provider Enumeration Date:
04/13/2006