Provider First Line Business Practice Location Address:
627 GLASS PIKE
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:
40324-8821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-535-6064
Provider Business Practice Location Address Fax Number:
502-535-5295
Provider Enumeration Date:
03/07/2007