Provider First Line Business Practice Location Address:
1504 S 7TH 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:
40208-1711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-636-5492
Provider Business Practice Location Address Fax Number:
502-636-9210
Provider Enumeration Date:
08/19/2020