Provider First Line Business Practice Location Address:
1917 S HIGHWAY 53
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA GRANGE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40031-8574
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-645-8539
Provider Business Practice Location Address Fax Number:
812-944-5496
Provider Enumeration Date:
10/24/2007