Provider First Line Business Practice Location Address:
1934 W JEFFERSON 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:
40203-1526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-384-7115
Provider Business Practice Location Address Fax Number:
502-709-5435
Provider Enumeration Date:
02/23/2026