Registry details
Type
Individual
Primary specialty
Family Medicine
Enumerated
Jul 17, 2012
License(s)
125-061897 (IL), 48150 (KY)
Addresses on file
| Purpose | Address | City/State | Phone |
|---|---|---|---|
| LOCATION | 119 FAIRFIELD AVE SUITE R102 | Bellevue, KY 41073 | 859-431-0090 |
| MAILING | PO BOX 635283 | Cincinnati, OH 45263-5283 | 859-431-0090 |
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