Provider First Line Business Practice Location Address:
808 S BROADWAY ST
Provider Second Line Business Practice Location Address:
STE. 9
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40324-2305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-863-2106
Provider Business Practice Location Address Fax Number:
502-863-2180
Provider Enumeration Date:
01/14/2006