Provider First Line Business Practice Location Address:
1006 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:
40031-9122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-222-0028
Provider Business Practice Location Address Fax Number:
502-222-0029
Provider Enumeration Date:
09/20/2006