Provider First Line Business Practice Location Address:
801 W BROADWAY
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:
40202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-386-0656
Provider Business Practice Location Address Fax Number:
502-244-5783
Provider Enumeration Date:
11/16/2006