Provider First Line Business Practice Location Address: 
7400 NEW LAGRANGE RD
    Provider Second Line Business Practice Location Address: 
SUIITE 315
    Provider Business Practice Location Address City Name: 
LOUISVILLE
    Provider Business Practice Location Address State Name: 
KY
    Provider Business Practice Location Address Postal Code: 
40222-4870
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
502-423-1975
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
05/07/2007