Provider First Line Business Practice Location Address:
1025 NEW MOODY LN
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:
40031-9154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-222-3886
Provider Business Practice Location Address Fax Number:
502-222-8647
Provider Enumeration Date:
10/03/2006