Provider First Line Business Practice Location Address:
1002 S 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:
40324-1463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-868-0422
Provider Business Practice Location Address Fax Number:
502-867-1967
Provider Enumeration Date:
09/03/2008