Provider First Line Business Practice Location Address:
105 E WASHINGTON ST
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:
40031-1215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-648-6988
Provider Business Practice Location Address Fax Number:
502-331-6062
Provider Enumeration Date:
03/09/2021