Provider First Line Business Practice Location Address:
4201 W HIGHWAY 146
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:
40031-9758
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-265-0184
Provider Business Practice Location Address Fax Number:
502-265-0184
Provider Enumeration Date:
01/21/2007