Provider First Line Business Practice Location Address:
10303 1/2 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:
40272-3951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-937-4930
Provider Business Practice Location Address Fax Number:
502-937-5296
Provider Enumeration Date:
08/16/2005