Provider First Line Business Practice Location Address:
309 W JEFFERSON ST STE B
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:
40031-1111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-225-4540
Provider Business Practice Location Address Fax Number:
502-225-4541
Provider Enumeration Date:
11/24/2006