Provider First Line Business Practice Location Address:
614 W BROADWAY
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:
40202-2212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-587-0394
Provider Business Practice Location Address Fax Number:
502-587-0390
Provider Enumeration Date:
01/14/2010