Provider First Line Business Practice Location Address:
42 LEGRANDE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HORSE CAVE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42749-7749
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-218-1373
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/14/2025