Provider First Line Business Practice Location Address:
645 S ROY WILKINS AVE
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:
40203-2072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-561-0520
Provider Business Practice Location Address Fax Number:
502-561-0521
Provider Enumeration Date:
10/25/2012