Provider First Line Business Practice Location Address:
2215 PORTLAND AVE
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:
40212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-774-8631
Provider Business Practice Location Address Fax Number:
502-776-8912
Provider Enumeration Date:
06/27/2005