Provider First Line Business Practice Location Address:
642 S 2ND ST
Provider Second Line Business Practice Location Address:
APT 1003
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40202-2433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-910-8797
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/05/2007