Provider First Line Business Practice Location Address:
1009 A DUPONT SQUARE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-894-9950
Provider Business Practice Location Address Fax Number:
502-894-9991
Provider Enumeration Date:
09/15/2006