Provider First Line Business Practice Location Address:
204 BEVINS LN STE D
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:
40324-6145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-967-3814
Provider Business Practice Location Address Fax Number:
859-241-6071
Provider Enumeration Date:
06/12/2026