Provider First Line Business Practice Location Address:
305 W BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40202-2129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-585-2924
Provider Business Practice Location Address Fax Number:
502-585-2931
Provider Enumeration Date:
10/17/2006