Provider First Line Business Practice Location Address:
4515 CHURCHMAN 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:
40215-1172
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-361-0134
Provider Business Practice Location Address Fax Number:
502-361-0137
Provider Enumeration Date:
10/17/2005