Provider First Line Business Practice Location Address:
1023 NEW MOODY LN STE 101
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-222-8540
Provider Business Practice Location Address Fax Number:
502-222-8505
Provider Enumeration Date:
10/05/2015