Provider First Line Business Practice Location Address:
12204 SHELBYVILLE RD
Provider Second Line Business Practice Location Address:
SUITE 4B
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40243-1450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-419-3092
Provider Business Practice Location Address Fax Number:
888-774-9458
Provider Enumeration Date:
03/27/2009