Provider First Line Business Practice Location Address:
2005 S HIGHWAY 53 STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAGRANGE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40031-9109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-330-0909
Provider Business Practice Location Address Fax Number:
812-330-0099
Provider Enumeration Date:
02/15/2007