Provider First Line Business Practice Location Address:
115 N BROADWAY ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40324-1301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-867-1336
Provider Business Practice Location Address Fax Number:
502-867-8164
Provider Enumeration Date:
05/29/2007