Provider First Line Business Practice Location Address:
1023 NEW MOODY LN STE 202A
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:
40031-9177
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-897-7172
Provider Business Practice Location Address Fax Number:
812-282-4172
Provider Enumeration Date:
04/12/2012