Provider First Line Business Practice Location Address:
112 OSBOURNE WAY
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:
40324-9636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-867-1224
Provider Business Practice Location Address Fax Number:
502-867-1226
Provider Enumeration Date:
06/24/2022