Provider First Line Business Practice Location Address:
313 W MADISON 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:
40031-1431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-667-0692
Provider Business Practice Location Address Fax Number:
502-225-6014
Provider Enumeration Date:
03/07/2012