Provider First Line Business Practice Location Address:
4414 OLD LA GRANGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUCKNER
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40010-9547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-222-2389
Provider Business Practice Location Address Fax Number:
502-222-2927
Provider Enumeration Date:
01/21/2009