Provider First Line Business Practice Location Address:
103 BOSTON SQ
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:
40324-9746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-619-5488
Provider Business Practice Location Address Fax Number:
502-570-9269
Provider Enumeration Date:
12/01/2006