Provider First Line Business Practice Location Address:
6745 BEULAH CHURCH RD
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:
40228-2415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-357-0895
Provider Business Practice Location Address Fax Number:
502-812-1931
Provider Enumeration Date:
08/07/2025