Provider First Line Business Practice Location Address:
112 HANEY CT
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:
40324-8664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-867-2287
Provider Business Practice Location Address Fax Number:
866-924-1957
Provider Enumeration Date:
08/31/2006