Provider First Line Business Practice Location Address:
302 N 1ST ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
LA GRANGE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40031-1502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-716-0360
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/10/2014