Provider First Line Business Practice Location Address:
2307 S HIGHWAY 53
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA GRANGE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40031-8568
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-225-6277
Provider Business Practice Location Address Fax Number:
502-225-6270
Provider Enumeration Date:
12/20/2006