Provider First Line Business Practice Location Address: 
5400 HEAFER FARM LN UNIT 203
    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: 
40219-7033
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
502-533-3340
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/27/2023