Provider First Line Business Practice Location Address:
134 N BROADWAY 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:
40324-1302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-433-1913
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/10/2026