Provider First Line Business Practice Location Address:
2005 S HIGHWAY 53
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LA GRANGE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40031-9109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-222-4613
Provider Business Practice Location Address Fax Number:
502-225-0882
Provider Enumeration Date:
04/22/2008