Provider First Line Business Practice Location Address:
1612 DAWKINS RD
Provider Second Line Business Practice Location Address:
BOX 67
Provider Business Practice Location Address City Name:
LA GRANGE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40031-8729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-222-7161
Provider Business Practice Location Address Fax Number:
502-222-7798
Provider Enumeration Date:
07/23/2006