Provider First Line Business Practice Location Address:
927 W MAIN ST
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:
40202-2621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-208-5787
Provider Business Practice Location Address Fax Number:
502-690-4364
Provider Enumeration Date:
11/20/2025