Provider First Line Business Practice Location Address:
501 S PRESTON ST
Provider Second Line Business Practice Location Address:
ROOM 306B
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40292-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-852-5126
Provider Business Practice Location Address Fax Number:
502-852-4388
Provider Enumeration Date:
01/12/2007