Provider First Line Business Practice Location Address:
627 S PRESTON ST
Provider Second Line Business Practice Location Address:
APT 3K
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40202-1743
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-771-1514
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/29/2009