Provider First Line Business Practice Location Address:
1038 S 17TH 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:
40210-2459
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-953-3399
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/26/2026