Provider First Line Business Practice Location Address:
143 E MAIN ST
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:
40324-1763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-312-3595
Provider Business Practice Location Address Fax Number:
800-746-0578
Provider Enumeration Date:
03/13/2012