Provider First Line Business Practice Location Address:
12406 LA GRANGE RD STE 202
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:
40245-1904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-243-3733
Provider Business Practice Location Address Fax Number:
502-243-3734
Provider Enumeration Date:
04/15/2008