Provider First Line Business Practice Location Address:
4500 DIXIE HWY
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:
40216-2875
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-919-9009
Provider Business Practice Location Address Fax Number:
502-919-9008
Provider Enumeration Date:
05/29/2019