Provider First Line Business Practice Location Address:
217 LA GRANGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEWEE VALLEY
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40056-9174
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-649-4441
Provider Business Practice Location Address Fax Number:
502-901-9287
Provider Enumeration Date:
06/09/2005