Provider First Line Business Practice Location Address:
189 OUTER LOOP
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:
40214-5544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-636-8668
Provider Business Practice Location Address Fax Number:
502-363-6533
Provider Enumeration Date:
08/22/2006